MUNICIPAL TESTING CORPORATION, INC. 375 Rabro Drive, Hauppauge, NY 11788 - Phone (631)761-5555, Fax (631)761-5560 ‘melmathew@mtllab.net Registration form & instructions Individuals certified through this program are typically expected to be capable of reading, comprehending, and executing procedures requiring strenuous physical activity, and possess a level of fitness required to safely execute the procedures, By marking the appropriate box below, you are asserting that you are aware of the physical abilities and fitness level appropriate to participate in the program without accommodation for either permanent or temporary disabilities in accordance with the ‘Americans with Disabilities Act (ADA), or have contacted ACI and are in the process of applying for accommodations in accordance with ADA. request participation without accommodations via ADA Tam in the process of applying for accommodations via ADA Municipal Testing Corporation is conducting the following ACI Certification test session on __1/31/2020 at 9 am @ 375 Rabro Drive, Hauppauge, NY_11788. (Use Front Door) Recertification Initia cert 1, ACI- CONCRETE FIELD TESTING TECH GRADE-1 Fee $595,00/pp_$695.00/pp. ACI- STRENGTH TESTING TECH Fee $595.00/pp $695.00/pp ACI- AGGREGATE TESTING TECH LEVEL ~ 1 Fee $695.00/pp $795.00/pp ACI- CONSTRUCTION SPECIAL INSPECTOR Fee $650.00/pp $650.00/pp 5. ACI CONCRETE LAB TECH IT Fee $ 750.00pp $850.00/pp CANCELLATION OR NO SHOW, Fee $100.00/pp $100.00/pp Please respond before 1/20/2020 by completing the information below and mail back to Municipal Testing Corporation, 375 Rabro Drive, Hauppauge, NY 11788, and Attn: Mel Mathew, Certification Manager, along with a business check in the appropriate amount payable to Municipal Testing Corporation. Credit cards are also accepted. PAYMENT IN FULL IS REQUIRED TO REGISTER, Please Print FULL NAME: PHONE?: Email Address: -X___ [understand that participation in this program does not guarantee certification or Employment if certification is attained. I further understand that employment in specific Geographic areas is contingent upon the laws and ordinances of that jurisdiction. SIGNATURE: ‘You must have safety shoes & glasses to (ake the performance examination, You will be cancelled if you DO NOT have them. Also please leave cell phones in car.