First and Last Name: 
Social Security #:     
Address:                    
City:                        
State:                      
Zip:                       
Initiation Date:           Local #:                
Work Phone:              Residence Phone: 
Cell Phone:             
Email Address:        

I have a minimum of Five (5) years experience in the HVACR Industry:Yes No

I am currently enrolled in an Apprenticeship Program:  Yes No

If yes, where:

I do solemnly swear and affirm that the above statements are true. I further realize that falsification of these statements shall be cause for disqualification.

By checking this box, I agree to abide by the following rules and regulations of certificate holders as set forth by the NITC certification committee.

As a holder of an NITC certification I agree not to make any false claims about the scope of my certification(s); I agree not to utilize an NITC certification in any manner that portrays NITC unfavorably; and furthermore, I agree not to engage in false or misleading advertising of my NITC certification.

I understand that NITC reserves the right to suspend or revoke my certification should I violate these obligations. Should my certification be revoked, I agree to cease and desist any and all references to being the "holder" of an NITC certification and shall return any certificates, including wallet sized photo identification cards, to NITC.

I agree not to utilize any written documents, reports, procedures, etc., with the NITC certification mark in any manner whatsoever that may be inaccurate or false.