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Baxter, Minnesota Classroom and Exam Dates 2019 Below are the dates for our 2018/2019 CWI Exam Prep Courses and corresponding AWS CWI Exam dates to be held at our facility in Baxter, MN . The following enrollment form is for the American Institutes CWI Prep Course. Please fill out this enrollment form and submit it by email to: [email protected] or Fax to: 218-270-3184) THE AWS CWI EXAM INITIAL APPLICATION IS A SEPERATE FORM WE HAVE SENT TO YOU THAT NEEDS TO BE FILLED OUT AND SENT DIRECTLY TO AWS ALONG WITH PAYMENT FOR YOUR EXAM. In section 4 of the AWS CWI Exam Initial Application choose Option III, CWI Examination Only, along with either AWS D1.1- Structural Steel Code or API-1104 Pipelines. This means you are taking your prep course from us and your AWS CWI exam at our location immediately following the Part B Hands-on Prep Course. Baxter, MN Schedule CWI Online Prep Course (Part A & C) Recommended Start Dates CWI Prep Course Onsite (Part B) Dates AWS CWI Exam Date Exam Application & Fee Must be submitted to AWS AWS Exam Site Code Used for Section Dec. 17, 2018 Jan. 28 - Feb. 1, 2019 Feb. 2, 2019 Dec. 21, 2019 MN60019 Feb. 18, 2019 Apr. 1-5,2019 Apr. 6, 2019 Feb. 22, 2019 MN60119 Apr. 22, 2019 Jun. 3-7, 2019 Jun. 8, 2019 Apr. 26, 2019 MN60219 Aug. 19, 2019 Sep. 30- Oct. 4, 2019 Oct. 5, 2019 Aug. 23, 2019 MN60419 IMPORTANT DATES! Your AWS CWI Exam Initial Application must be submitted to AWS no later than the dates below!

Baxter, Minnesota Classroom and Exam Dates 2019

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Baxter, Minnesota Classroom and Exam Dates 2019

Below are the dates for our 2018/2019 CWI Exam Prep Courses and corresponding AWS CWI Exam dates to be held at our facility in Baxter, MN . The following enrollment form is for the American Institutes CWI Prep Course. Please fill out this enrollment form and submit it by email to: [email protected] or Fax to: 218-270-3184) THE AWS CWI EXAM INITIAL APPLICATION IS A SEPERATE FORM WE HAVE SENT TO YOU THAT NEEDS TO BE FILLED OUT AND SENT DIRECTLY TO AWS ALONG WITH PAYMENT FOR YOUR EXAM. In section 4 of the AWS CWI Exam Initial Application choose Option III, CWI Examination Only, along with either AWS D1.1- Structural Steel Code or API-1104 Pipelines. This means you are taking your prep course from us and your AWS CWI exam at our location immediately following the Part B Hands-on Prep Course.

Baxter, MN Schedule

CWI Online Prep Course (Part A & C)

Recommended Start Dates

CWI Prep Course Onsite (Part B) Dates

AWS CWI Exam Date

Exam Application & Fee Must be submitted to

AWS

AWS Exam Site Code Used for Section

Dec. 17, 2018 Jan. 28 - Feb. 1, 2019 Feb. 2, 2019 Dec. 21, 2019 MN60019

Feb. 18, 2019 Apr. 1-5,2019 Apr. 6, 2019 Feb. 22, 2019 MN60119

Apr. 22, 2019 Jun. 3-7, 2019 Jun. 8, 2019 Apr. 26, 2019 MN60219

Aug. 19, 2019 Sep. 30- Oct. 4, 2019 Oct. 5, 2019 Aug. 23, 2019 MN60419

IMPORTANT DATES! Your AWS CWI Exam Initial

Application must be submitted to AWS no later than the dates

below!

__________________________________ _______________

___________________

_____________________________________ :___________________

_______________ I____

P_________

_____________ ____________ _______________________

Gender M

7938 College Rd

Suite 100 Baxter, MN 56425

ENROLLMENT AGREEMENT FOR CERTIFIED WELDING INSPECTOR PREPITORY COURSE

Personal Data Email: Phone:

Name: First M Last F

Address: City

State: ZI

Date of birth: / / U.S. Citizen Y N

Emergency Contact Information

Name: Phone: Relationship:

Tuition and Fees:

1. Tuition: Part A & C Online: $900.00 Part B in Classroom: $900.00

Part C Code Book: D1.1 1104

2. Total: $ Date of Classroom (Part B) Attendance

Payment Type:

Purchase Order#_____________

Credit Card# _______________

__________________

Credit Card Billing Address:

__________________

________

_________

____________________________

_

PREPARATION GUIDE FOR ATTENDING THE AMERICAN INSTITUTE OF NONDESTRUCTIVE TESTING PLEASE READ AND INITIAL THESE REQUIREMENTS

1. Initial _____ Complete the AWS Initial CAWI/CWI Exam Application and submit it with payment

for your exam directly to AWS at least six weeks before the examination date if you choose to take your exam at our facility immediately following the hands-on portion of our prep course.

2. Initial _____ Purchase your code book for exam (AWS D1.1 or API 1104) and bring it with you on

the first day of class. The code books are available at https://www.aws.org/product-category/books/welding-codes-specifications/ or directly from the publisher.

3. Initial _____ You may not use any electronic device, including cell phones, in place of a calculator

for your CWI Exam. Permitted calculators are scientific calculators, construction calculators, and four-function calculators. Please bring a notebook, pens/pencils, and your calculator. These will not be provided.

4. Initial _____ Book of Specifications (BOS) is provided by AWS on test day. The BOS used for

training cannot be used during the exam.

Buyers Signature: Date:

Print name:

AINDT Representative Signature: Date:

Print Name:

Be sure to read all pages of this agreement, as they are all part of your contract with the school. THIS IS A LEGALLY BINDING CONTRACT

REFUND POLICY Cancellation: Cancellation of attendance in any class by a prospective student (company) may take place up to two (2) weeks prior to the starting date for Part B of the course without charge. Notification to the American Institute of Nondestructive Testing within two (2) weeks prior to the starting date of Part B for cancellation of attendance in any CWI Preparatory Course will result in no refund, but the student will have the option to reschedule their classroom portion of the training depending on availability. Failure to notify of non-attendance or a “no-show” on the assigned starting date will result in the forfeiture of all payments of tuition for CWI Preparatory Course Part B.

GENERAL INFORMATION Purchase order policy: If tuition is invoiced against a purchase order, a copy of the purchase order must accompany the enrollment form. Terms are NET 30 on all invoiced training. Housing and meals: Students are responsible for their own housing and meals. Students may bring their own food, or there are several restaurants near the institute. Contact the institute at 218-270-3182 for information about restaurants, hotels, and campsites. Insurance and Medical Care: Students are responsible for their own medical care and expenses. Students are not covered by the American Institute of Nondestructive Testing insurance or industrial compensation. Safety and Health: We do not permit tobacco use inside the facility for the safety and health of other students and staff. However, the Institute does provide designated areas outside the facility for tobacco users. Shorts and open-toed shoes or sandals are not permitted in any American Institute of Nondestructive Testing classrooms or labs.

NOTICE OF CANCELLATION

Type of goods purchased

Date of transaction / /

If you do not want the goods or services described above, you may cancel your purchase by mailing or delivering a signed and dated copy of this cancellation or any other written notice or by phone to:

American Institute of Nondestructive Testing

7938 College Rd, Suite 100

Baxter, MN 56425

Phone: 218-270-3182

Not later than midnight of the fifth business day following the date of this contract. If you cancel, any payments made by you under the contract or sale will be returned within 30 days following the postmarked date of the notice of cancellation.

Although, if you cancel you must make available to the seller all materials provided by seller, in substantially as good condition as when received. These materials may be delivered to the address above, or if originally shipped to you, must be repackaged and ready for pick-up by USPS, UPS, FED EX, or carrier of sellers’ choice within 10 days of the postmarked date of this cancellation.

I HEREBY CANCEL THIS TRANSACTION

DATE:

Buyer’s Signature:

2015 Price List

Inspector (CAWI, CWI, SCWI) Price

Member *Non-Member

Initial CAWI, CWI or SCWI Exam - Add CWE Exam

850 140

1065 ***140

CWI by Reciprocity with CWB or INWC 500 715 Endorsement Exam 275 490 Upgrade CAWI to CWI 240 455

Retest Price

Member * Non-Member

CAWI, CWI, CWE or CWI/CWE (Per Part) 275 ***275

CAWI, CWI, CWE or CWI/CWE (All Parts) 595 810

SCWI 595 810

Packages Price

Member * Non-Member

CWI D1.1 Seminar and Exam Package - Add CWE Exam- CWI Pre-Seminar

2080 140 750

2295 ***140 ***750

CWI API-1104 Seminar and Exam Package - Add CWE Exam- CWI Pre-Seminar

2080 140 750

2295 ***140 ***750

Clinics / Seminars / Workshops Prices

Member * Non-Member

1585 1800 1585 1800 800 ***800 375 590

335 550 655

5 730 845

***1150

Renewal Prices

Member * Non-Member

CWI/SCWI 3rd and 6th Year Renewal by work Experience 470 685 CWI/SCWI 3rd and 6th Year Renewal by Examination 745 960 CWB or INWC Renewal by Reciprocity 430 645

9-Year RecertificationPrice

Member * Non- Member

CWI Part B Exam 870 1085 CWI Part B Exam and Visual Inspection Workshop 1090 1305 SCWI Exam 870 1085 CWI/SCWI Endorsement Exam 870 1085 CWI/SCWI Non-Exam

• 80 Professional Development Hours (PDHs) • Endorsement Exam Prior to 9th year of certification period • Initial CRI Certification

595 810

CWI/SCWI 9yr Course 1625 1840

NOTE: PRICES ARE SUBJECT TO CHANGE * Non-Member price includes a 3-year AWS Individual Membership unlessotherwise noted. ** Non-Member price includes a 1-year AWS Individual Membership. *** No additional membership included with this price.

To Review the AWS Policies and Fees, please visit our website at http://www.aws.org/certification/policiesfees/ Certification Price List February 25, 2015

Certified Welding Educator (CWE) Price

Member *Non-Member

Exam Only 635 850 Welding Inspection Technology (WIT) and Visual Inspection Workshop (VIW)

880 1095

Non-Exam 360 575 Retest 315 530 Renewal 305 520

AWS SENSE Participants Only Exam 275 490 Retest 315 530 CWE/CWI Exam 470 685 Renewal 200 415

Certified Radiographic Interpreter (CRI) Price

Member *Non-Member

Exam 750 965 Seminar 1340 1555 Seminar and Exam 1675 1890 Retest (All Parts) 550 ***550 Retest (Per Part) 275 ***275 Renewal 445 660

Certified Welding Supervisor (CWS) Price

Member *Non-Member

Exam 400 **480 Seminar 1250 **1330 Seminar and Exam 1550 **1630 Retest (Per Part) 275 ***275 Renewal 305 **385 9yr Recertification Exam 368 **460 9yr Recertification PDHs 336 **420

Certified Welding Sales Representative (CWSR) Price

Member *Non- Member

Onsite Exam 275 **355 Onsite Retest (Per Part) 275 ***275 Online Seminar and Exam 450 600 Online Retake Seminar and Exam 350 ***370 Renewal 275 ***275

Certified Welding Engineer (CWEng) Price

Member *Non-Member

Part 1 & 2 Exam 400 **480 Part 3 & 4 Exam 400 **480 PE Exemption 350 565 Retest (per part) 200 **280 Renewal 445 660

Certified Robotic Arc Welding (CRAW) Price

Member *Non-Member

Technician/Operator Exam or Retest 350 565

Operator to Technician Upgrade 100 **100

Technician/Operator Renewal 200 415

Certified Welder (CW) Price

Member *Non-Member

Certified Welder Application 35 ***35

Maintenance of Welder Certification 15 ***15

Initial CAWI/CWI Exam Application 1101 Page 1 of 7 February 7, 2018

Please use this checklist to ensure your application is processed in a timely manner. Incomplete application will not be processed. Application must comply with ALL items listed below.

Check sections for compliance.

Personal Information – Last, First, and Middle initial MUST be completed

Sec. 1: Payment Method – Payment must accompany this application

Sec. 2: Personal Information – Name must match your current government issued ID or Passport

Sec. 3: Exam Location – Site Code (if Applicable), Exam Date, City/State, and Submission Deadline

Sec. 4: Codebook Package Selection – select only ONE codebook for examination or Exam Only

Sec. 5: Associations – Type of Business, Job Classification and Technical Interests.

Sec. 6: Qualifying Education and Experience Requirements – must include a copy of degree

Sec. 7: Qualifying Work Experience – must be completed for each employer to meet minimum work experience requirement. All fields are mandatory.

Sec. 9: Visual Acuity Form – (VAF) examination shall be performed not more than 7 months prior to the date of the CWI examination or recertification (page 6 of this package)

Sec. 10: American Disabilities Act (ADA) – if applicable, candidate must print a copy of our ADA package andfollow the instructions.

Sec. 11 Photo Requirement – To learn more, review the information on how to provide a suitable photo for your walletcard on our web www.aws.org/certification

Sec. 12: Proof of Identity – current color copy of government passport or national ID

Sec. 13: Terms and Conditions – This section of the application must be read, checked, dated, and signed bythe applicant taking the exam.

Terms

1. Method of Payment - Payment must accompany this application AWS USE ONLY

Check if billing address is different from mailing, provide below.

Acct #: __________________________________ __________________________________________________________________

All checks and money orders made payable to AWS

Check or money order #_______________________

VISA MC AMEX Discover Date: ___________________________________

CC#:________________________________________________________ Exp: ___________________

SIGNATURE :____________________________________________________________ CVV: ___________________

Amt$: ______________________________CWI

Applicants Information:

Last Name: _____________________________ First Name: _________________________ Middle: ______________

CAWI/CWI INITIAL APPLICATION Checklist & Payment Form 8669 NW 36 St, # 130 Miami, FL 33166-6672

(800) 443-9353 or (305) 443-9353, ext. 273

Sec. 8: Employment Verification– must be submitted for the company signing this section. All fields are mandatory.

Name ____________________________________________ AWS Member # ____________________________

Initial CAWI/CWI Exam Application 1101 Page 2 of 7 February 7, 2018

INITIAL CAWI/CWI EXAM APPLICATION

Application must be completed and signed by the person taking the exam

2. Personal Information Name must match your current government issued ID or Passport

3. Exam Location - Confirmation will be emailed in 3-4 weeks from receipt

1st *Site Code: ________________ Exam Date: _________________ City/State: __________________________ Submission Deadline: __________________

2nd *Site Code: ________________ Exam Date: _________________ City/State: __________________________Submission Deadline: __________________

3rd *Site Code: ________________ Exam Date: _________________ City/State: __________________________ Submission Deadline: __________________

*Only if applicable NOTE: If the first choice is not available, registration will indicate the next available choice site. DO NOT make any hotel or flight arrangements until you have received your exam confirmation letter from the Certification Department via email.

Last Name First Name Middle Initial

Street Address City, State, Zip Code

Home Telephone Work Telephone Mobile Telephone

Email Date of Birth MM/DD/YY Last Four Digits of SS#

4. Code Book: choose one of the package options below, or select “CWI Examination Only”

I. D1.1 SEMINAR AND EXAM PACKAGE (code book included)

1. CWI Seminar Week (D1.1 Focus) 2. Online Resources (Includes D1.1 Training)3. Certification Exam

Add CWI Pre-Seminar to package (online course only)

III. CWI EXAMINATION ONLY

AWS D1.1 – Structural Steel Code

AWS D1.2 – Structural Aluminum Code

AWS D1.5 – Bridge Welding Code

AWS D15.1 – Railroad

AWS D17.1 – Aerospace

ASME Sections VIII (Div 1) & IX

ASME Section IX, B31.1 and B31.3

API-1104 – Pipelines

II. API 1104 SEMINAR AND EXAM PACKAGE (code book not provided)

1. CWI Seminar Week (API 1104 Focus)2. Online Resources (Includes API 1104 Training)3. Certification Exam

add CWI Pre-Seminar to package (online course only)

For code book editions and other exam information please refer to the CWI Body of Knowledge

Name ____________________________________________ AWS Member # ____________________________

Initial CAWI/CWI Exam Application 1101 Page 3 of 7 February 7, 2018

5. Associations TYPE OF BUSINESS (CHECK ONLY ONE) Job Classification (check only ONE) Technical Interests (check ALL that apply)

A Contract Construction

B Chemicals & Allied products

C Petroleum & Coal Industries

D Primary Metal Industries

E Fabricated Metal Products

F Machinery Except Elect. (incl. Gas Welding)

G Electrical Equip., Supplies, Electrodes

H Transportation Equip. - Air, Aerospace

I Transportation Equip. - Automotive

J Transportation Equip. - Boats, Ships

K Transportation Equip. - Railroad

L Utilities

M Welding Distributors & Retail Trade

N Misc. Repair Services (incl. welding Shops)

O Educational Services (Univ,Libraries,Schools)

P Engineering & Architectural Serv.(Incl.Ass.)

Q Misc. Business Services (Incl.Comm.Labs)

R Government (Federal,State,Llocal)

S Other

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21

22

President, owner, partner, officer

Manager,Director,Superint.(or assistant)

Sales

Purchasing

Engineer — welding

Engineer — other

Inspector, tester

Supervisor, foreman

Welder, welding or cutting operator

Architect, designer

Consultant

Metallurgist

Research & development

Technician

Educator

Student

Librarian

Customer service

Other

Engineer - design

Engineer - manufacturing

Quality Control

Robotics

Computerization of Welding

Ferrous Metals

Aluminum

Nonferrous Metals Except Aluminum

Advance Materials/Intermetallics

Ceramics

High Energy Beam Process

Arc Welding

Brazing & Soldering

Resistance Welding

Thermal Spray

Cutting

NDT

Safety & Health

Bending & Shearing

Roll Forming

Stamping & Punching

Aerospace

Machinery

Marine

Piping & Tubing

Pressure Vessels & Tanks

Sheet Metal

Structures

Other

Automation

Computerization of Welding

Name ____________________________________________ AWS Member # ____________________________

Initial CAWI/CWI Exam Application 1101 Page 4 of 7 February 7, 2018

6. Qualifying Education and Experience RequirementsCheck the box indicating your highest level of education. If using education for work experience, you must include a copy of transcripts forengineering, engineering technology, physical science or vocational education courses.

7. Qualifying Work Experience: - Resumes not accepted - ALL FIELDS ARE MANDATORY

DUPLICATE THIS SECTION FOR EACH ADDITIONAL EMPLOYER

8. Employment Verification• This section MUST be completed by a supervisor or personnel manager for the most recent or current employer indicated above.

• Self-employed or contract applicants must substitute this section with a letter of reference on company letterhead from two (2) separate clients attesting to:o the nature of work assignments during the period of performanceo type of work doneo length of time as a client

• If the employer is no longer in business, include a copy of the W2 form.

Company Name: _________________________________________ Company Phone: __________________________________________

Company Address: ___________________________________________________________________________________________________

City, State: __________________________________________________ Zip Code: _________________________ Country: _____________

I ______________________________________________ , verify that __________________________________ maintained employment at

________________________________________ from _________________________ to __________________________

Signature: _________________________________________________________________ Date: __________________________________

Minimum Education Level Minimum Work History

CAWI CWI

Completed less than 8th grade 6 years 12 years

Completed 8th grade (You can combine 1 yr. Vo-Tech + 3 yrs. Work Experience to meet the min. requirements for CAWI)

4 years 9 years

High Diploma or GED 2 Years 5 years

High school diploma plus one-year engineering/technical school courses or one or more years of vocational education and training in a welding curriculum.

1 Year 4 years

High school diploma plus two or more years engineering/technical school courses. 6 Months 3 years

Associate or higher degree in engineering technology, engineering, or a physical science. 6 Months 2 years

Bachelor or higher degree in welding engineering or welding technology 6 Months 1 year

Company Name Type of Business Company Phone Number

Company Street Address City, Province, Country, Postal Code

Supervisor’s Name Title of Immediate Supervisor

Supervisor’s Email Address Department

Applicant’s Job Title Dates of Employment From Month/Year

To Month/Year

Job Responsibilities Detailed Description Required

Supervisor/Personnel Manager’s Name (print)

Month/Day/Year

Supervisor/Personnel Manager’s Name (print)

Employee’s Name (print)

Company Name Date mm/yyyy Date mm/yyyy or Present

Name ____________________________________________ AWS Member # ____________________________

Initial CAWI/CWI Exam Application 1101 Page 5 of 7 February 7, 2018

9. Visual Acuity Form

A current Visual Acuity Form must be completed and submitted with this application (page 6 of this application).

10. American with Disabilities Act Accommodations

By checking this box, I am requesting special accommodations due to a disability. AWS is committed to complying fully withthe ADA. For a copy of the accommodations request package please visit our web: www.aws.org

Will you be using a glucose meter during your exam? Yes No

11. Photo Requirement

Applicants MUST submit one (1) passport-style color photograph. Your photo is a vital part of your application. To learn more, review the information on how to provide a suitable photo to avoid processing delays by visiting our website. The acceptance of your photo is always at the discretion of the AWS.

Print your name and AWS membership number on the reverse of the photograph.

DO NOT STAPLE OR PAPER CLIP PHOTO

12. Proof of Identity

Please attach a color copy of your current Government issued ID to this application, such as a driver’s license or passport.

13. Terms and Conditions- Please check, date, and sign below.

Certified Welding InspectorQC1 Standard for the AWS Certification of Welding Inspectors B5.1 Specification for the Qualification of Welding Inspectors

I hereby certify that I have read the standard requirements contained in the certification programs indicated above. Further, I agree to comply with the existing requirements and any subsequent requirements that may be instituted by AWS. I have read and agree to the terms and conditions set forth in the AWS Policies and Fees form. I certify that the information I have included on this application is true. I understand that any false statements will nullify this application. I give AWS permission to verify this information. I agree to comply with the provisions set forth in the Standard concerning the administration of my examination and certification. Upon obtaining my certification, I give AWS the right to reveal my certification status as it relates to my validity and expiration date. I further understand that any required information that is incomplete or missing will cancel this registration.

Furthermore, I certify that I have not obtained any exam materials, have no prior knowledge of the AWS exam questions or answers, and have not and will not accept any solicitation for the AWS exam questions or answers from anyone at any time before, during, or after the exam as stated on the Exam Security Agreement and General Terms of Use (Please read the Terms and Conditions. You will be required to sign this form on exam day). I understand that a violation of this oath may be grounds for invalidation of my certification and may be grounds for expulsion from any future testing.

Applicant’s Signature ________________________________________________ Date: ___________________________

Photos copied or digitally scanned from driver’s licenses or other official documents are not acceptable.

Name ____________________________________________ AWS Member # ____________________________

Initial CAWI/CWI Exam Application 1101 Page 6 of 7 February 7, 2018

VISUAL ACUITY FORM

Member #: _______________ Email Address: ______________________________________ Date:________________

Last Name: ________________________________ First Name: _____________________________ MI:___________

Applicant

This form must be submitted for all SCWI/CWI/CAWI/CRI/CWEng applications ONLY.

AWS will not release exam results, recertification results, or renewals without a completed Visual Acuity Record on file.

IMPORTANT: This completed Visual Acuity Form must be sent to the AWS Certification Department prior to the exam, or no later than 60 days after the certification exam date for your CAWI/CWI/SCWI/ or 30 days for the rest of the programs requiring a Visual Acuity Form. Applicants who have not fulfilled all requirements after the certification exam date shall have test scores and application voided, and may be in jeopardy of forfeiting application fees. This form may be sent via fax, email, or mail.

Eye Examination Eye examinations shall be administered by an Ophthalmologist, Optometrist, Medical Doctor, Registered Nurse or Certified Physician’s Assistant or by other ophthalmic medical personnel, and must include the state or province license number. Examinations shall be performed within one (1) year of the certification examination date, or within one (1) year of the certification expiration date for renewal or recertification of CWI/SCWI and seven (7) months for all other programs requiring a Visual Acuity Form. All applicants must pass an eye examination, with or without corrective lenses, to prove near vision acuity on Jaeger J2 at 12 in. or greater (≥30.5 cm). All applicants shall take a color perception test. Eye examination results must be documented on this Visual Acuity Record form supplied by the AWS Certification Department. No other forms will be accepted.

1. The following must be completed by the eye examiner:

A. Verify the customer’s close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater(≥30.5 cm)(Check ONLY one of the following for each eye)

AWS Use Only

OD OS

Requires corrected vision to read Jaegar J2 at 12 in. or greater. W

No correction is required to read Jaegar J2 at 12 in. or greater. O

Unable to read Jaegar J2 at 12 in. or greater even with attempt at correction. NQ

B. Through a color perception examination, is the applicant colorblind?(Check ONLY one of the following for each eye)

AWS Use Only

OD OS

Customer IS NOT colorblind C

Customer IS colorblind. B

3. Examiner’s Contact Information (print clearly)

Customer Name: Date of eye exam:

Examiner Name: Phone Number:

Examiner Address:

City: State: Zip/Postal Code: Country:

4. Examiner professional status (check only one)

Ophthalmologist Optometrist Medical Doctor Registered Nurse Certified Physician’s Assistant

Examiner Signature: State/Prov. License number: