API 580

Certification Program for Advanced Knowledge of Risk Based Inspection

Application Instructions

1. This application is a writable PDF. Please make sure to download the application document and save it on your computer. You can then open the application, type in your information, and print the application forms. (Any application filled in while viewing it online will not be saved, nor will it be sent to API electronically.) All applications must be mailed to API. 2. Fill out all pages of this application completely. 3. Please enter your name as it appears in your passport / government-issued ID / drivers license. 4. Please include your API ID number every place that your name appears in the application form. 5. You must include an Employment Confirmation Letter with the application. See Page 7 for full instructions. This requirement is waived for Inspectors who hold a valid certification in the API 510, 570, or 653. 6. Read and sign BOTH Inspector Agreements 7. Include the certification fee. See Page 2 for ICP Financial Policies. We will not process any application until full payment is received. 8. Be sure to keep a copy of the completed application that you mail to API. 9. When you have completed your application see checklist at the back of this packet to ensure you have included all the information and documents necessary. Be sure to include a unique and current e-mail address. All API correspondence will be sent to the e-mail address you provide. The exam is closed book and questions are taken from the API RP 580 document. See the Test Registration Form for the appropriate edition required. The publications for ICP certification exams may be ordered through IHS (www.global.ihs.com) or TechStreet (www.techstreet.com) INFORMATION FOR THE DAY OF THE EXAM: You are allowed to have only the following in the test room: Sharpened No. 2 pencils, an eraser and a calculator (simple function only, non-programmable). Anything else could be confiscated by the test staff.

ICP FINANCIAL POLICIES

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Payment Policy API cannot process any application until full payment is received. No exceptions will be made under any circumstances. Candidates WILL NOT BE PERMITTED TO TAKE AN ICP EXAMINATION if payment has not been received AND processed by API. Proof of payment must be included with your application.

API must RECEIVE your ORIGINAL application by mail on or before the application deadline. All payments must be made in United States currency. Paying by credit card provides the best opportunity to ensure that payment is received and processed by API in the timeliest manner. Checks must be drawn from a US bank. You are responsible for all taxes, banking or other service fees, including all applicable withholding taxes. If your company is going to pay the fee make sure they know the deadline and allow plenty of time for the company to make payment. If paying by wire transfer please submit a copy of the electronic transaction document with your application. The applicants name MUST be included on the wire transaction document. If the copy is not included with the application please e-mail a copy to inspector@api.org as soon as possible to allow time to identify the payment and schedule you for the exam.

Refund Policy
All requests for refunds must be submitted to API in writing by mail, e-mail or fax

and requested within 6 months of the date of the payment. For refund requests made before the application deadline: API will refund the initial certification fee less $100.00 for processing. For refund requests made after the application deadline: API will refund 50% of the initial certification fee. Reschedule fees are nonrefundable. For refund requests made after the date of your examination: No refunds will be issued whether you took the examination or not.

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API 580 Application Form Basic Information

Certification Program for Advanced Knowledge of Risk Based Inspection

New API Exam

EXAM ID #

(if previously assigned)

___________________________________________________________________________________________ FIRST MIDDLE LAST NAME (please spell it the same way as it appears on your passport / drivers license)

Home Address (Number and Street)

Date of Birth (Month / Day / Year)

City, State and Zip or Postal Code

Home Telephone Number

Country

Personal Email (At least one UNIQUE E-MAIL REQUIRED)

Employer Data

Work Telephone Number

Employer

Business Email (Unique e-mail not shared)

Employers Address (P.O. Box or Number and Street)

Cell Phone Number

City, State and Zip or Postal Code

If you want your exam admission letter / score report to be sent to your employer, trainer, or exam organizer, please include this persons e-mail here:

Country

Group Contact E-mail

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Additional Information
API 580, Certification Program for Advanced Knowledge of Risk Based Inspection
1. Mailing and Directory Addresses -- Please check the appropriate boxes regarding your preference for mailing and directory addresses. Please be sure to check one box only for each question. At which address do you wish to receive your certificate? Are you interested in being included in the on-line API Inspector Directory, when you obtain your certification? Which address do you want shown in the ICP Directory listing? 2. Do you currently have an active API certification? If yes, enter your certification number and expiration date. If you answer yes, you need not complete the Education and Training Form. Yes Home Yes Home No Work No Work

Program / Certification Number Program / Certification Number Program / Certification Number 3.

Expiration Date Expiration Date Expiration Date Yes No

Are you currently a full-time, non-contract employee of an API member company? If yes, please enter the company name.

4.

Please check the boxes that correctly describe your organization. Please be sure to check one box on each side. Industry Organization type

PETROLEUM CHEMICAL PAPER/PULP SERVING ALL INDUSTRIES OTHER

5.

OWNER-USER INDIVIDUAL CONTRACTOR INSPECTION COMPANY CONSULTING/CONSTRUCTION OTHER

Please check the boxes that correctly describe your employment status. Please be sure to check one box only.

Full-time employee of an owner/user Full-time employee of an inspection agency/other company Independent contractor

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Education and Training

Inspection

API 580, Certification Program for Advanced Knowledge of Risk Based

Please attach copies of your school / university diplomas.

High School / Secondary School

Name

Location

Year Graduated

Name

Location

Year Graduated

Trade / Vocational School

Name

Duration of Studies

Field of Study

Year Graduated

Name

Duration of Studies

Field of Study

Year Graduated

Name

Duration of Studies

Field of Study

Year Graduated

College / University

Name

Duration of Studies

Major

Degree Type

Dates Attended

Name

Duration of Studies

Major

Degree Type

Dates Attended

Name

Duration of Studies

Major

Degree Type

Dates Attended

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Employment History
API 580, Certification Program for Advanced Knowledge of Risk Based Inspection (Last three employers or at least the last five years)
1. Name and Address of Employer (Current) Employer Mailing Address (Number and Street) City, State and Zip Code Job Title / Description of Responsibilities Date of Employment From: ____________________ To: ____________________ ____________________ Employers Telephone

2.

Name and Address of Employer Employer Mailing Address (Number and Street) City, State and Zip Code Job Title / Description of Responsibilities

Date of Employment From: ____________________ To: ____________________ ____________________ Employers Telephone

3.

Name and Address of Employer Employer Mailing Address (Number and Street) City, State and Zip Code Job Title / Description of Responsibilities

Date of Employment From: ____________________ To: ____________________ ____________________ Employers Telephone

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Verification Requirements for Employment History Employment Confirmation Letters

ll candidates must have their employers submit an Employment Confirmation letter that will verify the years of experience and scope of activities that they have performed while under employment. If there are multiple employers to meet the minimum requirement, you must have each of the employers submit a letter.

The letter must be submitted on company letterhead, and signed by a company official such as HR/department manager, director, or vice-president. The letter must confirm the following: Name of applicant Dates of employment Job Title of the candidate Details of the job responsibilities Please Note: This requirement is waived for Inspectors who hold a valid certification in the API 510, 570 or 653. Please be sure to attach the letter of employment confirmation.

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API 580 Test Registration Applicants Name:

Exam ID #
_________________________________________
(If previously assigned):

FOR 580 Exams in in 2013-2014 Questions are based on the API RP 580, Second Edition, Published November 2009

Examination Locations and Dates

Please indicate your preferred exam date and location listed below.

September 25, 2013 (Application Deadline API must receive no later than July 10, 2013)

(Afternoon Exam Session)

Application deadlines are firm no exceptions will be made.

North America:
Anchorage, AK Atlanta, GA Baton Rouge, LA Corpus Christi, TX Edmonton, AB (Canada) Houston, TX Indianapolis, IN Los Angeles, CA Oakland, CA Oklahoma City, OK Philadelphia, PA

Other Locations:
Abu Dhabi, UAE Al-Khobar, Saudi Arabia Cairo, Egypt Chennai, India Chia, Colombia Doha, Qatar Kuala Lumpur, Malaysia Mumbai, India Port of Spain, Trinidad Safat, Kuwait Singapore, Singapore United Kingdom (Contact API for city info)

If a location of your choice is not listed above please contact API for more information. If you are testing at an API-approved special site, please include the location and/or group here:_________________________________________
City, Country

> > THIS FORM MAY ALSO BE USED TO RESCHEDULE A TEST << If rescheduling, please remember to include the re-test fee.

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Inspector Certification Agreement - 1

(Effective on Date of Inspectors Certification)
This Agreement is between the American Petroleum Institute (hereinafter API), a corporation of the District of Columbia, having an office at 1220 L Street, N.W., Washington, D.C. 20005, and the Applicant (the Inspector), residing at the address noted below. Whereas, APIs Individual Certification Programs (ICP) certify inspectors and other technical personnel that meet the guidelines and requirements specified in the program. Whereas, Inspector desires to obtain certification under the API ICP program. Now therefore, in consideration of the mutual covenants hereinafter stated, the parties agree as follows: 1. Inspector agrees to comply with all of the program policies and requirements. Inspector agrees and understands that API shall be the sole judge of whether the Inspector has the appropriate qualifications to become certified, remain certified, or to be recertified. 2. The Inspector agrees not to make any misrepresentations concerning the Inspectors certification status or the program. The Inspector agrees not to perform any acts, which directly or indirectly assist a third-party in making any misrepresentation relating to the ICP program. The Inspector understands and agrees that the ICP Program is designed to assist users in identifying inspectors who have satisfied the minimum qualifications specified in the applicable industry standards and that API does not warrant or guarantee the competency of any inspector certified under this program. The inspector agrees not to mislead customers or the public about the scope and purpose of this program. The Inspector authorizes API to release information to regulatory agencies, current or potential employers, or other interested parties concerning the inspectors certification status. API agrees to take reasonable measures to ensure that any information that is released is accurate. However, API does not warrant or guarantee the accuracy of any information that is released and specifically disclaims any liability relating to the release of this data. The Inspector understands and agrees that the Inspectors certification will not be renewed unless the inspector satisfies all of the program requirements for renewal and submits the appropriate recertification application and renewal fee to API within the time frame specified by API. Inspector understands and agrees that API may modify the requirements for an inspector to obtain, maintain, or renew the certification at any time. If APIs requirements are modified, API shall determine the date by which the new requirements become effective. Inspector agrees to comply with the modified requirements within the deadline specified by API. API agrees to attempt (but assumes no duty) to notify Inspector of significant changes to the program by either giving notice (1) the Inspectors last known e-mail address, or (3) by posting the changes on the API website. It is the responsibility of the Inspector to notify API of address changes. The failure of API to notify Inspector of a renewal date or modification of the program does not relieve the Inspector of the responsibility to file a timely renewal application or to comply with new certification requirements. It is the responsibility of the Inspector to obtain this information by contacting API or by checking the API website for updates. If any action or proceeding is brought by API to enforce, protect or establish any right or remedy with respect to this Agreement or with respect to the subject matter of this Agreement, API shall be entitled to recover reasonable attorney's fees and costs provided that it is the prevailing party. Inspector agrees to indemnify API for any losses or damages resulting from the breach of the terms of this Agreement by the Inspector. The Inspector agrees and understands that API may terminate an inspectors certification if API determines that the inspector has: (1) made material errors, omissions, or misrepresentations on the application or in documents submitted to API, or (2) violated any terms or conditions of this Agreement or any ICP policies or requirements. API also may terminate the program at any time and for any reason deemed appropriate by API. Upon termination, with or without cause, of any rights or authority conferred by this Agreement, or upon expiration/termination of the Inspectors certification, Inspector agrees to return all certification documents to API within 30 days. The Inspector shall not use any trademark of API or name of API including any abbreviation thereof, in any publicity, advertising, or for other promotional purposes without the prior written approval of API.

3.

4.

5.

6.

7.

8.

9.

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10. The Inspector agrees to comply strictly with all U.S. export laws relating to this program. The Inspector warrants that he is not located in, or under the control of, or a national or resident of any embargoed countries. 11. This agreement shall not and is not intended to benefit or to grant any right or remedy to any person or entity that is not a party to this Agreement. 12. This instrument contains the entire and only agreement between the parties. No oral statements or representations not herein contained shall have any force and effect. 13. Paragraphs 2, 3, 4, 5, 6, 7, and 8 survive termination of this agreement. 14. It is expressly understood between the parties hereto that no association, agency, apparent agency, employer/employee relationship, partnership, or joint venture of any kind has been created. Inspector agrees not to refer to himself as APIs agent nor refer to the relationship between the parties as a joint venture or partnership or in any manner inconsistent with this Agreement. Inspector shall have no authority to act or contract on behalf of API. 15. No waiver by API of any default, misrepresentation, or breach of warranty or covenant hereunder, regardless of whether intentional, shall be deemed to extend to any prior or subsequent default, misrepresentation, or breach of warranty or covenant hereunder or affect in any way any rights arising by virtue of any prior or subsequent such occurrence. 16. API makes no express or implied warranties regarding the ICP program or potential benefits of the certification to the Inspector. 17. The Inspector agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any government body or authority in any way measured by this Agreement, or any portion of it, or any services related thereto. 18. Inspector understands and agrees that Inspector is not granted any rights under the program or this Agreement until API has determined that the Inspector has satisfied all of the program requirements and has issued a Certificate to the Inspector. The Inspectors certification shall be effective on the date that is noted on the Certificate and shall be effective for a period of three years unless terminated pursuant to the terms of this Agreement. 19. This Agreement shall be governed by and construed in accordance with the laws of the District of Columbia, USA, without regard to the rules regarding conflicts of law. The parties agree that any action, suit, or proceeding based upon any matter, claim, or controversy arising hereunder or relating hereto shall be brought exclusively in the federal or state courts located in District of Columbia, USA. The parties consent to the jurisdiction and venue of such courts, and waive any objections to the jurisdiction and venue thereof.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to comply with the conditions specified above. Applicants name (please print) _____________________________ E-mail: _________________________

___________________________________ Signature of Applicant

_________________ Date

Applicants address: ______________________________________________ ______________________________________________

API Reviewers Initials: ____________

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Inspector Application Agreement - 2

(for Initial and Renewal Certification)
(Effective upon Receipt of Application)
The applicant agrees to the following conditions: 1. API agrees to evaluate the applicants qualifications to determine if the Inspector satisfies the requirements of the ICP program. Applicant understands and agrees that: (1) API will not issue an ICP certificate to the Applicant unless API determines that an Applicant meets all of the requirements and Applicant has submitted the applicable fees and documentation within the specified time frame, and (2) API shall be the sole judge of whether the Applicant has the appropriate qualifications to become certified, remain certified, or be recertified. The Applicant agrees to pay the applicable fees, comply with all of the program requirements and submit any supplemental information or documents deemed necessary by API to verify an applicants qualifications. Applicant understands and agrees that API does not represent or warrant that the submission of the fees and materials by the Applicant will result in the Applicant being certified under the program. Each new application remains valid for a period of 12 months from the date of receipt by API. API grants each applicant three attempts during the 12-month period to sit and pass the test, starting with the first exam administration the applicant registers for. Applicants must pass the exam within these three exam administrations. If an applicant fails to appear for the test, cancels his/her appearance and reschedules, or takes the exam and fails it, it will count as an official attempt. If the applicant does not obtain a certification within this period of time and still wishes to obtain the certification, they must start the application process again, including re-submission of a full fee and a complete new application. All requests for refunds must be submitted in writing by mail, e-mail or by fax to API no later than 6 months from the date payment was received by API. Requests for refunds received after this period cannot be fulfilled. An applicant is entitled to a full refund of the application fee, minus a processing fee, only if API receives the refund request prior to the exam application deadline. An applicant is entitled to a 50% refund of the application fee if the refund request is received by API within 6 months from the date payment was received by API and the candidate cancelled in advance of the examination date. No refunds will be made if an applicant has taken the test or did not show up without prior notice. For normal processing API must receive recertification applications prior to the current certifications expiration date. Recertification applications must be mailed, as API requires the original of the notarized page.

2.

3.

4. 5. 6. 7. 8. 9.

10. API may extend the certification term for 3 (three) months after the expiration date. Inspectors will remain authorized during that period of time. Recertification applications received by API within this extension term will be processed, but a $150.00 late fee will be required. 11. Inspectors who do not apply for recertification within three months after the current certification expiration date will be decertified. 12. Circumstances such as heavy work schedule or work in other countries do not relieve the applicant of the responsibility to file a timely renewal application. 13. Applicant understands and agrees that API may modify the requirements for an applicant to obtain, maintain, or renew the certification at any time. If APIs requirements are modified, API shall determine the date by which the new requirements become effective. Applicant agrees to comply with the modified requirements within the deadline specified by API. API agrees to attempt (but assumes no duty) to notify Applicant of significant changes to the program by either giving notice: ( (1) the Applicants last known e-mail address, or (3) by posting the changes on the API website. It is the responsibility of the Applicant to notify API of address changes. The failure of API to notify Applicant of a renewal date or modification of the program does not relieve the Applicant of the responsibility to file a timely renewal application or to comply with new certification requirements. It is the responsibility of the Applicant to obtain this information by contacting API or by checking the API website. 14. The Applicant agrees to comply strictly with all U.S. export laws relating to this program. The Applicant warrants that he is not located in, or under the control of, or a national or resident of any embargoed countries.
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15. The Applicant agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any government body or authority based on in any way measured by this Agreement, or any portion or it, or any services related thereto. 16. Applicant warrants and represents to all information that is being submitted pursuant to this is complete and accurate. Applicant understands that API is relying upon the accuracy of this information in evaluating the Inspectors qualifications. Applicant agrees to indemnify API for any claims, losses, or damages resulting from the Applicant submitting inaccurate or misleading information.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to abide by the policies and regulations specified above.

Applicants name (please print) ____________________________

E-mail: ___________________________

___________________________________ Signature of Applicant

_________________ Date

API Reviewers Initials ________________

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API 580 - PAYMENT INFORMATION Applicants Name: _________________________________________

Exam ID #
(If previously assigned):

API member rate applies to full-time, non-contract employees of API-member companies.

API Member
$225.00

Non Member
$275.00

PAYMENT INSTRUCTIONS
All payments must be made in United States currency. Checks must be drawn on a U.S. bank. You are responsible for all taxes, banking or other service fees, including all applicable withholding taxes. Applicants name(s) must be included on the check. For payments by electronic transfer: (1) you are responsible for all electronic transfer, A.C.H. and banking fees (be sure to add the fees to your payment); (2) for electronic payments not drawn on a U.S. bank a fiftydollar ($50) handling fee must be added at the time payment is made. Please include a copy of the wire / electronic transaction. Applicants name(s) must be included on the transaction document.

PAYING BY CREDIT CARD CAN EXPEDITE THE PROCESSING OF YOUR APPLICATION AND PAYMENT TO ENSURE YOUR PLACE IN THE EXAMINATION.
Credit Card Type: Card Number: Visa American Express Expiration Date: _____________________________________________
Initial Certification Fee Reschedule / Retest Fee

MasterCard

Name as it appears on card Signature

_______________________________________

E-mail address to send receipt:

Check

($75.00)
Late Penalties Bank Fee (if wired)

Wire Transfer to:

TD Bank
1030 15th St NW Washington, DC 20005 USA ABA Routing # 054001725 Credit to: American Petroleum Institute Account # 4251303172 SWIFT: NRTHUS33

TOTAL SUBMITTED

(Reference: Applicants Name and SS-2100-D9200-7110) Your application will not be processed if this page is not completed.

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CHECKLIST
1. 2. 3. 4. 5. 6. 7. All pages of the application completed Valid e-mail address included so we can contact you Employment Confirmation letter (s) attached. BOTH Inspector Agreement forms signed Certification Fee (payment page filled in completely) Copy of transaction documentation if paying by wire Copy of completed application made for your records

MAIL ORIGINAL APPLICATION TO: API Individual Certification Programs 1220 L Street, NW Washington DC 20005 (Phone: 202-682-8064) Please include candidates name(s) on all payments.

IF PAYING BY CHECK OR MONEY ORDER, MAIL APPLICATION TO: API Individual Certification Programs P.O. Box 1425 Merrifield, VA 22116

TO SEND CHECKS BY COURIER, PLEASE ADDRESS PACKAGE TO: API Attn: John Robertson 1220 L Street, NW Washington, DC 20005 Phone 202-682-8064

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