APPLICATIONFORTHENATIONALBOARDRCERTIFICATEOFAUTHORIZATION [1] NEWAPPLICATION [2] RENEWAL [3] REVISIONTOPREVIOUSAPPLICATION

(i.e.,nameoraddresschange,etc. refertoNBIC,Part3,1.6.3fordetails.)

[4]

THE NATIONAL BOARD

OF BOILER AND PRESSURE VESSEL INSPECTORS

PrintyourcompanynameexactlyasitappearsinyourQCManual(Punctuation,spacingandcapitalizationofthenameareimportant).

Abbreviationtobeusedforstamping(ifapplicable)

[5] [8]

[6]

ApplyingFor:

[7]

ROnlyor

RwithASME

CheckAllRequestedScopes:
[9] [13]

Repairs Alterations Both

[10] [14]

Shop Field Both

[11] [15]

[12] Metallic NonMetallic (FRP,Graphite,etc.)

DesignOnly

AuthorizedInspectionAgencyor Owner/UserInspectionAgencyOrganization:

[16]

REVISIONSONLY:($50.00revisionfeewillapply)
AuthorizedInspectionAgencyacceptance:
[17]

SignatureofAuthorizedInspectionAgencyRepresentative
[18]

Date

NewApplicantsandAIAChanges:
Alongwiththisform,pleaseencloseacopyofthecontractcoverpage withyourAIA&acopyofthecoverpageofyourQCManual.

Effectivedateofcontract:

BYSIGNINGTHISFORM,YOUACKNOWLEDGETHATYOUHAVEREADANDUNDERSTANDTHECONDITIONSANDTHESTATEMENTOFDUEPROCESSAND CONFIDENTIALITYONPAGE2OFTHISAPPLICATION. [19] [20] Signatureofcompanysauthorizedrepresentative Printname&titleofcompanysauthorizedrepresentative date

Note:Ifyouhaveanorganizationalchangeatanytimewhichaffectstheprimarycontactwithinyourcompany,theNationalBoardmustbe notifiedinwritingassoonaspossiblewiththenewinformation(contactperson,phonenumber,faxnumberand/oremailaddress).

Tobecompletedbyapplicant:
[21] PhysicalAddress(asitappearsinyourQCManual) [22] City,State,Province,Country,PostalCode [25a] NameofCompanysPrimaryContact [26] TelephoneNumber [28] EmailAddress [29] WebAddress [27] FaxNumber [25b] Title ofCompanysPrimaryContact [24] City,State,Province,Country,PostalCode [23] MailingAddress

NationalBoardUse:

CertificateNumber

DateIssued

DateRevised

ExpirationDate

AccreditationDept

StaffEngineer

CompanyID#

AmountPaid

Date

CheckNo/TypeofCC

Page1of3NB12Rev.19

Conditions
The Certificate and R Symbol Stamp shall be used only by the named company and in the manner prescribed in the National Board InspectionCode(NBIC).ThecompanymusthaveallpartsofthecurrenteditionoftheNBICwithallapplicableaddendawhenperforming workundertheCertificateofAuthorization. The certificate and stamp will be surrendered should the company discontinue the above activities, at the request of the National Board or at the expiration of the certificate. The company will pay anyand all legal fees andNational Board costs associated with the recovery ofthecertificateandstamp. The National Board member jurisdiction or the National Board may make audits or unannounced visits as deemed necessary to ensure compliancewiththerulesoftheNationalBoard. Under no circumstances shall the National Board R Symbol Stamp be used without the acceptance of a National Board CommissionedInspector.

StatementofDueProcessandConfidentiality
A Review Team will conduct an evaluation of the companys Quality System. The company must demonstrate sufficient implementation oftheQualitySystemtoprovideevidenceofthecompanysknowledgeofwelding,nondestructiveexamination,postweldheattreatment andotherrepairoralterationactivitiesperformedasapplicablefortherequestedscopeofwork. The Review Teams responsibility is to document any findings and report them to the National Board along with a recommendation concerningissuanceofaCertificateofAuthorization. Team members are prohibited from discussing this companys proprietary information as well as the information contained in their reportatanytime,unlesswithNationalBoardstafforAppealsCommitteemembers.Informationobtainedbytheteammember,staffor committeememberswillbeheldinstrictconfidence.Acopyoftheirreportwillbeleftwiththeapplicantuponrequest. NationalBoard policyprovidesfordueprocessbyanaggrievedparty.Individualsmayrequestinformationconcerningthisprocedureby contactingtheAppealsCommittee,1055CrupperAvenue,Columbus,Ohio432291183orfax614.847.1828.

Submitcompletedformto: TheNationalBoard,1055CrupperAvenue,Columbus,Ohio432291183

RecommendedAirport:City

NameofAirport:
[30b]

[30a]

Doyourecommendrentingacar?
[31a]

Alternatemodeoftransportation:
[31b]

Yes

No

(IfNo,pleasecomplete[31b])

Monday Tuesday Wednesday

Hotel/MotelforReviewTeam:
FirstChoice:
[32]

[33]

SecondChoice:
Hotel/MotelName

[34]

Hotel/MotelName

Address Telephone Milesfromairporttolodging Milesfromlodgingtoshop(reviewlocation) Approximatetaxicost

Address Telephone Milesfromairporttolodging Milesfromlodgingtoshop(reviewlocation) Approximatetaxicost

Pleasecheckthedaysoftheweekthatyourcompanyisopenforbusiness:
Sunday Thursday Friday Saturday

PleaseNote:Anincomplete/improperlycompletedapplicationmaydelaytheprocessingofthisrequest.Pleasebesure yourformisCOMPLETEbeforesubmitting.Thankyou.

NationalBoardUse:
Date Hotel ConfirmationNumber Page2of3NB12Rev.19

GUIDEFORCOMPLETINGTHEAPPLICATIONFORTHENATIONALBOARDRCERTIFICATEOFAUTHORIZATION
[1] [2] [3] [4] [5] [6],[7]&[8] [9] [10] [11] [12]

[13] [14] [15] [16] [17]

[18] [19] [20] [21]&[22] [23]&[24] [25a]&[25b] [26] [27] [28] [29] [30a] [30b] [31a] [31b] [32] [33] [34]

CheckthisboxisthisisanapplicationforyourfirstRCertificateofAuthorization. CheckthisboxifthisisanapplicationforarenewalofanexistingRCertificateofAuthorization. CheckthisboxisthisisanapplicationforarevisionofanexistingRCertificateofAuthorization. PrintyourcompanynameexactlyasitappearsinyourQualityControlManual.Punctuation,spacingand capitalizationofthenameareimportant. SupplytheexactabbreviationusedformarkingorstampingasrequiredbytheNBIC.Forexample,Acme BuildingCompanymayuse(ABC)fortheirnameforthestamping. AreyouhavingareviewforanRstamponlyorwillyoualsobeapplyingforanASMEstamp(s)? Checkbox[7]or[8]. ChecktheboxifyourprogramonlycoversrepairsasdefinedintheNBIC. ChecktheboxifyourcompanywillbeperformingworkonlyattheaddressontheCertificateof Authorization(seeSHOPinNBICPart3,Section9). Checktheboxifyourcompanywillbeperformingworkonmetallicpressureretainingitems. Checktheboxifyourcompanywillbeperformingcodecalculationsforreratingoralterationsasdefined intheNBICandwillnotperformphysicalworktothepressureretainingitemexceptfortheRstamping orNDE. ChecktheboxifyourcompanywillbeperformingalterationsonlyasdefinedintheNBICandwillperform physicalworktothepressureretainingitem. Checktheboxifyourcompanywillbeperformingcodecalculationsorphysicalworkwhichiscontrolled fromtheaddresslistedontheCertificateofAuthorization. Checktheboxifyourcompanywillbeperformingworkonnonmetallicpressureretainingitemssuchas FRPorgraphite. NameofyourAuthorizedInspectionAgencyorOwnerUserorganization. Whenrevisingyourcurrentcertificate,anAuthorizedInspectionAgencyrepresentativeshallacknowledge acceptanceofthisrevisionbysigningthislineorprovidingaletterofacceptancetotheAccreditation Department. Supplyeffectivedateofthecontract/agreementwithyourcompanysAuthorizedInspectionAgency,as applicable. Signatureofyourcompanysauthorizedrepresentative.Requiredforbothnew&renewalapplications andrevisions. Printthename&titleoftheauthorizedrepresentativethatsignedline19. Physicaladdress(shop)aslistedinyourcompanysQualityControlManual.Thisisalsotheaddressthat willappearonyourCertificateofAuthorization. Mailingaddress,ifdifferentfromyourphysicaladdress. Printthenameandtitleofyourcompanysprimarycontact.ThisisthepersontheNationalBoardwill contactwithanyquestionsorconcerns. Telephonenumberofyourcompany. Faxnumberofyourcompany. Emailaddressofyourcompanywhichisroutinelymonitored. Websiteofyourcompany.Ifyourcompanydoesnothaveawebsite,pleasenoteN/A. PrintthecityoftherecommendedairportwheretheTeamLeaderwillarrive. PrintthenameoftheairportorairportcodewheretheTeamLeaderwillarrive. DoyourecommendtheTeamLeaderrentacar? IfyouhavecheckedNoonline[31a],listanalternatemodeoftransportation. Providecompleteinformationforthefirstchoicehotel/motel. Providecompleteinformationforthesecondchoicehotel/motel. Checktheboxesofthedaysoftheweekyourcompanyisopenforbusiness(foraReview).

**IfyouhaveanyquestionspleasecontacttheAccreditationDepartmentat614.888.8320**
Page3of3NB12Rev.19