Practical Examiner - Application

You must submit this application in order to verify your eligibility to be trained as a Practical Examiner to administer Crane Institute Certification (CIC) Practical Exams. This application consists of Background Information, a Release to allow us to verify the information on your application, and Payment.

Instructions

1. Print full application.
2. Complete all fields in the application. Please print clearly.
3. Mail the completed application to the address at the bottom of the page.

Background Information

In connection with your application to become authorized as a CIC Practical Examiner, all information on the application is subject to verification. You will need to agree that CIC may contact references and educational institutions listed on your application and consent to a background check. 

Print your full legal name.
Last: First: Middle:
List additional names you have been employed or enrolled under.
Last: First: Middle:
Last: First: Middle:
Social Security #:
Home Phone: Business Phone:
Email: Date of Birth (mm/dd/yy):
List your residential addresses for the past seven years:
Street Address 1 (current address):
City: State: Zip:
Street Address 2:
City: State: Zip:
Street Address 3:
City: State: Zip:
Street Address 4:
City: State: Zip:
Street Address 5:
City: State: Zip:
Signature: Date:

Education
Name & Location of Educational Institutions attended, starting with most recent. Degree Received Major / Specialty Dates Attended
       
       
       
Relevant Work Experience: Please list your work experience for the past five years beginning with the most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:
 
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:
 
Job Title: Job Duties:
From: (mm/yy)                  To: (mm/yy) Reason for Leaving:
Company Name:
Street Address 1:
City: State: Zip:
Supervisor Name: Phone:

Job Skills: Use the following space to provide any additional information that you think would be helpful in our evaluation of your skills to be a Practical Examiner.
 
 
 
 
 
 
 
 
Licenses Held (including drivers) or certifications to practice a trade or profession.
Type License Number Granted by (licensing board)
     
     
     
     
     
List up to three people who you would like to use as a reference.
Full Name Address Phone Number Relationship
       
       
       
Geographic Preference: Indicate cities/states where you would like to work:
Compliance with the Immigration Reform and Control Act: I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States. ___Yes ___No
Prior Convictions.
During the past 7 years, have you been convicted of a felony?   ___Yes ___No
 
If yes, then please provide the following:
Location:
 
Date of Conviction (mm/yy):
 		 Describe the Offense:
Location:
 
Date of Conviction (mm/yy):
 		 Describe the Offense:

Location:

Date of Conviction (mm/yy):
 

 Describe the Offense:

When would you like to take the Practical Examiner Training? mm/dd/yy
(check www.CraneInstituteCertification.com/pe_training.php or call Barbara Weedin at 800-832-2726 for available dates)
Available Start Date: When will you be available to start giving exams? mm/dd/yy
Do you wish to be listed as a Practical Examiner available to all Exam Sites on the CIC web site (see List Your Services on CIC)?     ___Yes  ___No
In order to be a Practical Examiner you must demonstrate knowledge of the crane type(s) you will be examining by:
    • Passing the CIC Crane Operator Certification written exams that correspond to the practical exams to be conducted
    • - OR - Provide proof of a valid, authorized practical examiner or crane operator certification, card from a nationally accredited entity that correspond to the practical exams to be conducted.*

    *CIC Examiner Authorization will be valid only for the time remaining on the existing authorization.

Release

I hereby certify that all entries on this job application and any attachments are true and complete. I also agree and understand that any falsification of this information may result in my forfeiture of authorization as a CIC Practical Examiner.
 
I certify that I am able to fulfill the Responsibilities of a CIC Practical Examiner.
 
In connection with my application to become a Crane Institute Certification (CIC) Authorized Practical Examiner, I understand that all information on the application is subject to verification. I agree that you may contact references and educational institutions listed on my application. I also consent to a background check.
 
 
Print your full legal name (Last Name, First Name, Middle):
Signature: Date:

Certification Exam Confidentiality Agreement

In any capacity that I work with Crane Institute of America Certification (CIC) (i.e., Practical Examiner, Proctor, Chief Examiner, Site Coordinator, Governing
Committee (i.e. Board of Commissioners), Advisory Board, consultant or member of a work team or subcommittee) I, the undersigned, accept responsibility for
maintaining the strict confidentiality and custodianship of all Crane Institute Certification (CIC) examination-related materials.


Examination related material, existing or in development, must be kept secure throughout its preparation, review, administration, and scoring. By signing this form,
I am agreeing to assume personal responsibility for keeping this material in a secured location at all times from when I receive the CIC exam materials until they
are returned to CIC. The specific examination security standards with which I will comply are:

  1. Keep all exam material secure until returned to CIC
  2. I will ensure that no person copies any exam materials in any format without express written consent of the acting CIC Executive Director
  3. Return all exam material, including any rough drafts, to CIC. Do not retain or copy any exam material for my own files.
  4. Discuss this exam only during formal exam development or review meetings. Topics that may not be discussed with others include, but are not limited
    to, exam items and responses, scoring standards, the identities and performances of examinees, exam results, and your evaluation of the exam.


If you are found to have violated this security agreement, you will be liable for civil action.

As a Practical Examiner I further agree that I will be objective and independent of the candidate taking the exams. To insure independence I agree to NOT conduct
an exam for any person I knew prior to exam registration or for whom I have an interest in the outcome of their exam. In addition, I will notify CIC immediately upon
realizing that I do not meet the requirements for independence.


I have read and understand the provisions of this Security Agreement. My signature below signifies that I agree to the terms of this agreement.

Print your full legal name (Last Name, First Name, Middle):
Signature: Date:

Payment

Please include a check payable to 4ROI for $695 with your application to cover the following services.
  • 4 hours of on-line or classroom training
  • 2 days on site training, training site, crane, and training materials
  • Initial site support with individual follow-up
  • Application processing
  • Examiner test and scoring, letter and certification card
  • Ongoing customer service
Any travel requested of trainer would be paid separately at cost to training provider.


Please mail your application and check made payable to 4ROI to:


4ROI
One Carlson Parkway, Suite 230
Minneapolis, MN 55447
Attn: CIC Examiner Application Request

You can also fax or e-mail in your application with a credit card number to:
763-476-4765 (fax)
Help@4ROI.com