Jul 28, 2011 ... ACCP Application for Level II and Level III JIS Z 2305. Certificate Holders. JSNDI
PCP app. 1 of 9. 7/7/09. ASNT Identification Number.
ACCP Application for Level II 赤字部分は、試験コード“2PE-PT-D” and Level III JIS Z 2305 に合格した場合の記入例（参考）です。 Certificate Holders
ご自分の申請内容に合わせて必要事項の 記載を行ってください。 ※ASNT よりダウンロードした本書類はレターサイ ズ（8.5×11 ｲﾝﾁ）となっています。レターサイズ の設定が無い印刷機器の場合は、 A4 サイズに変更し、出力してください。
ASNT Identification Number
If you have previously been given an ASNT identification number, please enter it in this box:
Personal Data Mail certification information to: Name
Home
Work
ＴＡＲＯＵ ＨＩＨＡＫＡＩ
活字体で記載
Print your name as you would like it to appear on your certificate: First, Middle or Middle Initial, Last
Home Name of the building, house number, street, town/village
Work
City
Prefecture/State/Province.
Postal Code
Phone
Fax
Email
Country
The Japanese Society for Non-Destructive Inspection Organization Name
MBR 99 Bldg., 4th Floor 67 Kanda-Sakumagashi Address
Chiyoda-Ku
Tokyo
101-0026
JAPAN
City
State/Prov.
ZIP/Postal Code
Country
+81-3-5821-5101
+81-3-3863-6524
[email protected]
Phone
Fax
Email
Certifications Requested
PE ｾｸﾀｰに合格した認証申請者 (check the boxes below to show which ACCP certifications are being requested)
は、GI と PE の両方にﾁｪｯｸを入 NOTE: If the Pressure Equipment (PE) Sector is being requested, you must complete the PE Sector Experience Section on page 3. れること。
Level II: Test Method MT
Industry Sector (Select one or both) GI PE
Techniques (Mark each Technique for which certification is sought) Yoke
Bench
PT
GI
PE
Solvent-Removable
Water-Washable
RT
GI
PE
X-Ray Only
X-Ray & RAM
UT
GI
PE
Welds Only
Castings/Forgings
合格した試験コードに対応するＮＤＴ技 法を全てﾁｪｯｸすること。 Test Methods
Level III: Industry Sector (Select one or both) GI
Post-Emulsifiable
(Level IIIs must be certified in all Techniques in each Test Method selected)
PE
MT
PT
RT
UT
Fees (All fees are listed in US dollars) Certification Fee: Mailing Surcharge: Membership Option:
(See page 2 to calculate your Certification Fee then place it here:)
$
For all Non-US Residents (to cover International Mailing charges) You can save on certification fees by becoming an ASNT member. Complete the membership application on pages 8 & 9 and include the membership fee total here:
$
Fee Total:
$
525.00 $40.00
565.00
Payment Payment is to be submitted to the Japanese Society for Nondestructive Inspection (JSNDI) in a form suitable to JSNDI. JSNDI PCP app
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Certification Fees ACCP Level II ACCP Level II certification fees are made up of three items: an Application fee, the Technique fee and an International Surcharge. The Application fee is a fixed fee that is charged once per application. The Technique fee is based on the number of NDT Techniques selected and whether or not you are a current ASNT Member. The International Surcharge is applied to all non-US residents to cover the additional cost of international mailings. To determine your Certification Fees, do the following: 1) Count the number of Techniques you applied for in the Certifications Requested table on page 1; 2)
If you are a current ASNT member, multiply that number by $50.00: _______Techniques x $50.00 =
3)
If you are NOT an ASNT member, multiply that number by $125.00:
3 _______Techniques x $125.00 =
NOTE: If you are not currently an ASNT Member, you can fill out the membership application on pages 8 & 9, then take advantage of the ASNT Member pricing. 4)
$
$
375
Place the amount from the appropriate box above and place that amount in the table below as your Technique Fees;
Certification Fee Type
Amount
Application Fee: Member Technique Fee (From box on Line 2 above): Non-Member Technique Fee (From box on Line 3 above):
$150.00 $ $375.00
Certification Fee Total (Total of Application and Technique Fees): $525.00 5)
Go back to page 1 and place the Certification Fee Total above in the block titled "Certification Fees".
ACCP Level III ACCP Level III certification fees are made up of three items: an Application fee, the Test Method fee and an International Surcharge. The Application fee is a fixed fee that is charged once per application. The Test Method fee is based on the number of NDT Test Methods selected and whether or not you are a current ASNT Member. The International Surcharge is applied to all non-US residents to cover the additional cost of international mailings. To determine your Certification Fees, do the following: 1) Count the number of Test Methods you applied for in the Certifications Requested table on page 1; 2)
If you are a current ASNT member, multiply that number by $95.00: _______Test Methods x $95.00 =
3)
If you are NOT an ASNT member, multiply that number by $170.00:
$
_______Test Methods x $170.00 = $
NOTE: If you are not currently an ASNT Member, you can fill out the membership application on pages 8 & 9, then take advantage of the ASNT Member pricing. 4)
Place the amount from the appropriate box above and place that amount in the table below as your Test Method Fees;
Certification Fee Type
5)
Amount
Application Fee: Member Test Method Fee (From box on Line 2 above): Non-Member Test Method Fee (From box on Line 3 above):
$210.00 $ $
Certification Fee Total (Total of Application and Test Method Fees):
$
Go back to page 1 and place the Certification Fee Total above in the block titled "Certification Fees".
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Document Submittals
パスポートの写真を貼付。 必ずサインを行うこと。
The following documents* must be submitted with this application: 1) A copy of your currently valid JIS Z 2305 NDT certificate issued by JSNDI;
2) A valid (within 12 months) vision examination showing near visual acuity to Jaeger J-1 or equivalent; and 3) One (1) passport photograph. Applicants must also provide a signature in the block below, which will be scanned and transferred electronically onto their ACCP wallet card. The signature must stay completely within the block with no overlap onto the block borders.
Attach passport
Signature Block:
photo here
Tarou Hihakai * The essential information (name, Levels, test methods, Techniques, etc.) on all documents must be in English. Hand-written translations are acceptable.
Pressure Equipment Sector Experience ACCP certification in the Pressure Equipment (PE) Sector requires three (3) years of documented experience in pressurerelated inspection. Applicants wishing to certify in the Pressure Equipment Sector must fill out the form below and have it signed by a JSNDI, ASNT NDT, ACCP Professional Level III or an Authorized Inspector. Photocopy this page as necessary to document your experience. List positions in reverse chronological order. １
Position #
Dates of Employment
November 1,2005 Start Date
Organization Name
Employer Contact Name Organization Address
61
December 1,2010 End Date
Total Time (Months)
以下の必要事項を記入。 ※必要な場合は、この頁をコピーして Position＃2、3・・・を記入する。 書類は、日付の新しいものから古いものへの順番で並べる。
City
State/Prov.
ZIP/Postal Code
Phone
Fax
Email
Country
In the space below, provide a summary of the type of work performed during this engagement. Include the inspection equipment used, the level of responsibility, and list specific inspection functions performed as described above. 記入例１ I have taken about 330 sheets radiographs of a pipe line welding and evaluated the films from August 2008 to September 2011. 記入例２ I worked as a UT Level II inspector for Power Boilers for in-service-inspection of drums at the ABCD power station from August 2008 to September 2011, and I have detected some cracks in welds.
I have reviewed this application and hereby attest that the experience times claimed by the above applicant are true and correct to the best of my knowledge. I understand that should the above information be found fraudulent, the applicant’s certification may be revoked and other penalties may apply. ＩＣＨＩＲＯＵ ＨＩＨＡＫＡＩ Printed Name
Ichirou Hihakai
March 18,2011
Signature
Date
Ｍａｎａｇｅｒ/ Quality Control Division
JIS Z 2305 LevelⅢ(PT) N87654321
Position/Title
The Japanese Society for Non-Destructive Inspection
ASNT NDT, ACCP Professional Level III or JSNDI Level III Certification No.
or
Company
AI* Certificate No.
*A photocopy of the AI’s currently valid certification card must be attached to this application when an AI signs off on the experience. JSNDI PCP app
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Affirmation of the Applicable Code of Ethics for Personnel Certified by ASNT By signature on this application, if certified by ASNT, I agree to abide by the applicable* Code of Ethics for Personnel Certified by ASNT so long as I maintain a Certificate. Further, I understand the right of ASNT to suspend or revoke any Certificate granted if I abuse the privileges therein granted to me. I understand that certifications which may result from this application do not constitute any form of license. I hereby attest that all facts on this application are true and correct and no information which might be detrimental has been withheld. ASNT may make any inquiries necessary to determine my qualifications for certification. I agree to abide by the decision of ASNT relative to the granting of any Certifications as applied for herein. For valuable consideration, the undersigned, having made application for Certification as Level II and/or Level III before ASNT, does hereby release and forever discharge The American Society For Nondestructive Testing, an Ohio Corporation, from any and all liabilities, claims, demands, or causes of action whatsoever, which now exist or which may hereafter arise on account of the undersigned’s activities henceforth as Level II and/or Level III certified by ASNT. The undersigned further acknowledges that this release is being given as a prerequisite for having filed application for consideration by ASNT. The undersigned further represents that if not certified by ASNT, then this release and discharge shall have no force and effect; otherwise, upon certification as set forth above, this release shall be binding on the undersigned and The American Society for Nondestructive Testing, Inc. and any and all agents of ASNT in connection with such certification process. I have read and understand the transfer, cancellation and refund policy. I have read and understand the attached transfer, cancellation and refund policy and understand that all application documents submitted to ASNT become the property of ASNT. I authorize ASNT to publish my name, city, state, country, test methods, Levels and expiration dates of certification.
活字体で記載。 ＴＡＲＯＵ
ＨＩＨＡＫＡＩ
Print Name of Applicant
必ずサインを行うこと。
Tarou Hihakai Signature of Applicant
March 25,2011 Date
* The ACCP Level II and the ASNT Level III Codes of Ethics are shown on pages 6 & 7 respectively.
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活字体で記載。
Vision Requirements Candidate Name (please print): ＴＡＲＯＵ
ＨＩＨＡＫＡＩ
Eye Exam Date:March 16,2011
Vision examinations shall be administered by a physician, licensed nurse, ophthalmologist or optometrist, or by personnel approved by the employer’s Level III. The visual examination date must be within 12 months of the date that this application is signed. The form below may be used to document this requirement.
Near distance vision Candidates must have visual acuity in at least one eye capable of reading the Jaeger J1 test chart, or equivalent, at the distance specified on the chart for J-1 text, but no less than 30.5 cm (12in.)
Color vision You must be able to differentiate between the colors used in the NDT method(s) for which certification is required.
Attestation of Visual Acuity I attest that I have administered the following vision examinations to the candidate named above: Near distance visual acuity in at least one eye capable of reading the Jaeger J1 test chart, or equivalent, at the distance specified on the chart for J-1 text, but no less than 30.5 cm (12in.). The candidate
passed (check one)
did NOT pass
this examination
with (check one)
without
correction.
I further attest that I administered a color perception examination on the candidate named above, and that the candidate has: No Color Perception Deficiency
Color Perception Deficiency (Specify):
Hanako Hihakai
March 20,2011
Signature of Eye Examiner
Date
Ophthalmologist/Optometrist Employer’s Level III
Physician Certificate No:
Other (Approved by the Employer’s Level III):
Registered Nurse
N12345678
Expiration Date:
Sep,31,2012
JIS Z 2305 LevelⅢ(PT)
Title:
Employer Attestation (for Candidate Color Perception Deficiency) If the candidate has a color perception deficiency, the candidate’s ability to distinguish colors used in the applicable method(s) as specified by the employer must be confirmed by the employer or a designated and responsible agent of the employer (such as an ASNT Level III, ACCP Professional Level III, or company Level III per SNT-TC-1A). I attest that the above named candidate has sufficiently demonstrated the ability to distinguish colors used in the applicable test method(s) as specified in employer procedures.
Employer/Agent Signature
Date
Employer/Agent Name (print)
ASNT ID (if applicable)
6/9page 以降については プリント内容をご確認のう え各自でご検討下さい。
Title
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Refund Policy If a certification application is received and the applicant is found to be unqualified to be certified for the requested Level or Test Method(s), a refund will be issued less an administrative fee of $75.00 PER METHOD. The International Surcharge and Membership / Administrative Fees are non-refundable and non-transferable. No exceptions will be made to the above policy.
Code of Ethics for ACCP™ Level II Personnel Certified by ASNT 1.0
Purpose 1.1 The following Code of Ethics is binding upon every individual who possesses a current ACCP™ Level II Certification. These rules are necessary to protect the life, health, property and welfare of the public, and to maintain the credibility of the ASNT Central Certification Program and the NDT profession. Accordingly, each ACCP™ Level II certified individual agrees to:
2.0
Code of Ethics 2.1 Responsibility: Protect the safety, health and welfare of the public, by performing all NDT activities to the best of his/her ability in accordance with properly established and approved procedures and only in situations for which qualified. 2.2 Integrity: Perform all NDT activities honestly, and treat the public, clients and employer in an impartial and ethical manner. All reports of NDT activities shall faithfully and accurately reflect the tests conducted, procedures used, and results obtained. 2.3 Conflict of Interest: Consciously avoid conflict of interest situations with employer or client, promptly informing same if such situations cannot be avoided. 2.4 Improper Conduct: Refrain from work activities outside the area of certification without written approval of his/her supervisor. 2.5 Safety: Act in a safe and responsible manner while conducting NDT activities, ensuring that all required and necessary safety procedures are in place and are being used by one’s self and others under his/her jurisdiction.
3.0
Penalty Violation of this Code of Ethics by any ACCP™ certified Level II person may be cause for disciplinary action against that person.
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Code of Ethics for Level III Personnel Certified by ASNT 1.
2.
3.
4.
Preamble 1.1. In order to safeguard the life, health, property, and welfare of the public, to maintain integrity and high standards of skills and practices in the profession of nondestructive testing, the following rules of professional conduct shall be binding upon every person issued a certificate by ASNT as a Level III. 1.1.1. The Level III who holds a certificate is charged with having knowledge of the existence of the reasonable rules and regulations hereinafter provided for his/her conduct as ASNT Level III, and also shall be familiar with their provisions and understand them. Such knowledge shall encompass the understanding that the practice of nondestructive testing under this certification is a privilege, as opposed to a right, and the Level III shall be forthright and candid in statements or written responses to the Ethics Committee of the Certification Management Board. 1.1.2. The “Level III” as referred to herein is that individual who has been issued a certificate by the American Society for Nondestructive Testing, Inc. pursuant to its heretofore published requirements, rules, and procedures for such certification. This Code of Ethics is binding upon all individuals so certified. Integrity 2.1. The Level III is obligated to act with complete integrity in professional matters for each client or employer as a faithful agent or trustee; shall be honest and impartial; and shall serve the public, clients, and employer with devotion. Responsibility to the Public The Level III shall: 3.1. Protect the safety, health, and welfare of the public in the performance of professional duties. Should the case arise where the Level III faces a situation where the safety, health, and welfare of the public are not protected, he/she shall: 3.1.1. Apprise the proper authority if it is evident that the safety, health, and welfare of the public are not being protected; and 3.1.2. Refuse to accept responsibility for the design, report, or statement involved; and 3.1.3. If necessary, sever relationship with the employer or client; and 3.1.4. Undertake to perform assignments only when qualified by training and experience in the specific technical fields involved. In the event a question arises as to the competence of an Level III to perform an assignment in a field of specific discipline which cannot be otherwise resolved to the Ethics Committee’s satisfaction, the Ethics Committee, either upon request of the Level III, or by its own volition, may require him/her to submit to an appropriate inquiry by or on behalf of the Ethics Committee; and 3.1.5. Be completely objective in any professional report, statement, or testimony, avoiding any omission which would, or reasonably could, lead to fallacious inference, finding, or misrepresentation; and 3.1.6. Express an opinion as a technical witness before any court, commission, or other tribunal, only when such opinion is founded upon adequate knowledge of the facts in issue, upon a background of technical competence in the subject matter, and upon an honest conviction of the accuracy or propriety of the testimony. Public Statements 4.1. The Level III will issue no statements, criticisms, or arguments on nondestructive testing matters connected with public policy which are inspired or paid for by an interested party, or parties, unless he/she has prefaced the remark(s) by explicitly identifying himself/herself, by disclosing the identities of the party, on whose behalf he/she is speaking, and by revealing the existence of any pecuniary interest he/she may have in these matters. 4.2. The Level III will publicly express no opinion on a
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5.
6.
7.
8.
9.
nondestructive testing matter unless it is founded upon adequate knowledge of the facts in issue, upon a background of technical competence in the subject matter, and upon honest conviction of the accuracy and propriety of the testimony. Conflict of Interest 5.1. The Level III shall conscientiously avoid conflict of interest with the employer or client, but when unavoidable, shall forthwith disclose the circumstances to the employer or client. 5.2. The Level III shall promptly inform the client or employer of any business associations, interests, or circumstances which could influence his/her judgment or the quality of services to the client or employer. 5.3. The Level III shall not accept compensation, financial or otherwise, from more than one party for services on the same project, or for services pertaining to the same project, unless the circumstances are fully disclosed to, and agreed to, by all interested parties or their duly authorized agents. 5.4. The Level III shall not solicit or accept financial or other valuable consideration from material or equipment suppliers for specifying their products. 5.5. The Level III shall not solicit or accept gratuities, directly or indirectly, from contractors, their agents, or other parties dealing with the client or employer in connection with work for which he/she is responsible. 5.6. As an elected, retained, or employed public official, the Level III (in the capacity as a public official) shall not review or approve work that was performed by himself/herself, or under his/her direction, on behalf of another employer or client. Solicitation of Employment 6.1. The Level III shall not pay, solicit, nor offer, directly or indirectly, any bribe or commission for professional employment with the exception of payment of the usual commission for securing salaried positions through licensed employment agencies. 6.2. The Level III shall seek professional employment on the basis of qualification and competence for proper accomplishment of work. 6.3. The Level III shall not falsify or permit misrepresentation of his/her, or his/her associates’, academic or professional qualification. He/she shall not misrepresent or exaggerate the degree of responsibility in or for the subject matter of prior assignments. 6.4. Brochures or other presentations incident to the solicitation of employment shall not misrepresent pertinent facts concerning employers, employees, associates, joint ventures, or past accomplishments with the intent and purpose of enhancing qualifications and work. Improper Conduct 7.1. The Level III shall not sign documents for work for which he/she does not have personal professional knowledge and direct technical supervisory control and responsibility. 7.2. The Level III shall not knowingly associate with, or permit the use of, his/her name or firm name in a business venture by any person or firm which he/she knows, or has reason to believe is engaging in business or professional practices of a fraudulent or dishonest nature. Unauthorized Practice 8.1. Any violation of this code shall be deemed to be an unauthorized practice and upon proper complaint, investigation, due process hearing and ruling of the Ethics Committee of the ASNT Certification Management Council in accordance with procedures heretofore established and published, sanctions may be applied to the individual(s) in violation. Rulings of Other Jurisdictions Conviction of a felony while ASNT certification is valid or the revocation or suspension of a Professional Engineer’s License by another jurisdiction or similar rulings by other professional associations may be grounds for a charge of violation of this Code.
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ASNT Individual Membership Application & Renewal Form Member Information Last Name
First Name
Send Membership Materials to:
О Home
M.I.
О Office
Join now for immediate and significant savings on examination fees. Save $75 per method.
Align with your certification period and consider joining for five years to receive maximum savings. There is no better network for you to be connected when it comes to your NDT career. Stay informed throughout your certification period by maintaining membership along with your certification. ASNT membership keeps you informed of the latest in technology in addition to savings on certification exams.
Become part of the foremost nondestructive testing society and be fully connected to the NDT world.
ASNT membership includes: • 25% discount on all items purchased from our Publications Catalog or Shop ASNT online at www.asnt.org
Membership Options
New Member Dues
Renewal Member Dues To qualify to pay as a renewing member, your membership expiration date must be within six months.
Dues
Renewal Member Two-Year Three-Year Five-Year Student, One-Year Must submit transcript or letter or enrollment
Military Rank E-5 or lower
О No
• Access to the largest network of NDT contacts and businesses worldwide • Materials Evaluation, the authoritative monthly journal on NDT • Local Section affiliation, provides educational and business networking opportunities • The quarterly newsletter for NDT practitioners: The NDT Technician • Recertification points for membership • Discounts on national conferences and symposium registration • Members Only access at www.asnt.org provides publications and networking functions • Serve on ASNT committees; be part of a group that may effect change or the industry
Earn recertification points for ASNT membership.
One-Year
О Yes
Former Member:
Phone
О О О О О О
New members are those joining ASNT for the first time or members having more than a six month gap since expiration. Such rejoining members, are subject to new member rate.
*Dues with Airmail
*New Member
*Dues with Airmail
Service included
Dues
Service included
$65 $125 $180 $290 $15 $30
О О О О О О
$113 $209 $294 $465 $63 $78
О О О О О О
О О О О О О
$75 $135 $190 $300 $15 $30
$123 $219 $304 $475 $63 $78
Dues include subscriptions to Materials Evaluation and The NDT Technician. For members outside North America: Unless airmail is specified, all materials w will be sent sea/surface mail; allow 3-4 months for delivery. *Airmail service is restricted by availability or cost; airmail may not be offered to your country. You will be contacted if service cannot be provided.
All pricing subject to change. New member dues include a one-time $10 administration fee Dues are nonrefundable, nontransferable. Dues include subscription to Materials Evaluation and The NDT Technician.
Research in Nondestructive Evaluation (RNDE®) Individual Subscription With Airmail Service Included
RNDE® is ASNT’s quarterly research journal. Print Subscription - for current volume
О $55 О $55 О $75
Electronic Subscription - for current volume Print and Electronic Subscription - a savings of $35
О $129
Add a subscription to ASNT’s quarterly research journal, RNDE.
О $149
All pricing subject to change.
Total Membership Amount $ Please enter total amount in membership box on page one and add to total.
Be sure to complete the questions on the next page. JSNDI PCP app
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Membership Profile 1. Year of Birth 2. Gender
9. Choose the one business segment that best describes your company. (select only one) О Male
О Female NDT Utilization Business
О Aerospace/Aviation/Aircraft О Amusement Rides & Skiing О Automotive О Chemical & Petroleum О Construction О Commercial Labs О Infrastructure (Roads & Bridges) О Electronics О Marine
3. Highest Education Level О Grades 1 - 12 О High School Diploma О Some College О 2-Year Associate Degree О 4-Year Undergraduate Degree О Master's Degree О Doctorate Degree 4. Years of Experience in NDT
О1-5 О6-10 О11-15 О16-20 О21 & over 5. Number of people involved with NDT at your company
О1-5 О6-20 О21-50 О51-100 О over 100
NDT Supplier Business О Consulting О Distributor/Manufacturer's О Representative О Equipment О Research
6. Your Job Function - Choose the one that 10. best describes your role. (select only one) О NDT Management О Sales/Marketing О Quality Management О Researcher О Engineer О Academic/Educator О Technician/Inspector О Trainer/Instructor О Consultant О Student
7. Purchasing Responsibility (select all that apply) I recommend/approve the purchase of: О Equipment/Instruments/Supplies О Training & Study Materials/Programs О Services О I am not involved in purchasing 8. With which NDT method(s) do you work? (select all that apply) О Acoustic Emission О Alternating Current Field Measurement О Electromagnetic/Eddy Current О Ground Penetrating Radar О Infrared & Thermal О Laser О Leak О Liquid Penetrant
О О О О О О О О О
Medical Nuclear Optical Ordnance Pipeline Pulp/Paper Railroad Semiconductor Utilities
О О О О О
Robotics Supplies Training Computer Software Computer Hardware
Choose the primary type of NDT that you do. (select only one) О Design and Failure Analysis О Field Inspection О Incoming Inspection
О In-service, Plant/Operation Maintenance & Process Control О Product Life Extension О QA/QC Reliability О None of the above
11. Highest Level of NDT qualification (select only one) О None О О Level I О О Level II О О Level III О
О О О О О О О
ASNT NDT Level III ACCP Level II ACCP Level III IRRSP
Magnetic Flux Leakage Magnetic Particle Neutron Radiography Radiography Ultrasonics Vibration Analysis Visual
For Questions Contact the Membership Department at: Phone 614.274.6003 JSNDI PCP app
Toll Free 800.222.2768 (US/Canada) 9 of 9
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