Application Form Basic Information

API 570, Piping Inspector Certification Program

Y

New API Exam

MOHANAD

EXAM ID #

(if previously assigned)

ABDULRAHMAN HASHIM

___________________________________________________________________________________________
FIRST
MIDDLE
LAST
NAME (please spell it the same way as it appears on your passport / drivers license)

SAB`ABKAR / M: 340 / ST: 80 / H: 30

01/13/1979

Home Address (Number and Street)

Date of Birth (Month / Day / Year)

BAGHDAD, 10055

(+9647503302951)

City, State and Zip or Postal Code

Home Telephone Number

IRAQ

mohanedrs979@yahoo.com

Country

Personal Email
(At least one UNIQUE E-MAIL REQUIRED)

Employer Data

Work Telephone Number

N/A
Employer

Business Email (Unique e-mail not shared)

Employers Address (P.O. Box or Number and

Street)

Cell Phone Number

City, State and Zip or Postal Code

If you want your exam admission letter / score report

to be sent to your employer, trainer, or exam
organizer, please include this persons e-mail here:

Country

Group Contact E-mail

Additional Information
API 570, Piping Inspector Certification Program
1.

2.

Mailing and Directory Addresses -- Please check the appropriate boxes regarding your
preference for mailing and directory addresses. Please be sure to check one box only for
each question.
At which address do you wish to receive your certificate?

Home

Work

Are you interested in being included in the on-line API Inspector

Directory, when you obtain your certification?

Yes

No

Which address do you want shown in the ICP Directory listing?

Home

Work

Yes

Do you currently have an active API certification?

No

If yes, enter your certification number and expiration date. If you

answer yes, you need not complete the Education and Training Form.

3.

Program / Certification Number

Expiration Date

Program / Certification Number

Expiration Date

Program / Certification Number

Expiration Date

Are you currently a full-time, non-contract employee of

an API member company?

Yes

No

If yes, please enter the company name.

4.

Please check the boxes that correctly describe your organization. Please be sure to check
one box on each side.
Industry

5.

PETROLEUM

Organization type

OWNER-USER

CHEMICAL

INDIVIDUAL CONTRACTOR

PAPER/PULP

INSPECTION COMPANY

SERVING ALL INDUSTRIES

CONSULTING/CONSTRUCTION

OTHER

OTHER

Please check the boxes that correctly describe your employment status. Please be sure to
check one box only.

Full-time employee of an owner/user

Full-time employee of an inspection agency/other company
Independent contractor

Education and Training

API 570, Piping Inspector Certification Program

Please attach copies of your school / university diplomas.

High School / Secondary School

TECHNICAL COLLEGE

BAGHDAD, IRAQ

2000

Name

Location

Year Graduated

ALSWIESS

BAGHDAD, IRAQ

1996

Name

Location

Year Graduated

Trade / Vocational School

Name

Duration of Studies

Field of Study

Year Graduated

Name

Duration of Studies

Field of Study

Year Graduated

Name

Duration of Studies

Field of Study

Year Graduated

College / University

TECHNICAL COLLEGE

4 YEARS

Name

Duration of Studies

TECHNICAL COLLEGE

4 YEARS

Name

Duration of Studies

Major

Degree Type

Dates Attended

Name

Duration of Studies

Major

Degree Type

Dates Attended

BSC WELDING ENGINEERING

Major

Degree Type

Dates Attended

MSC WELDING ENGINEERING

Employment History
API 570, Piping Inspector Certification Program
(Must list last three employers to cover at least the last five years of employment)
1.

Name and Address of Employer (Current)

Employer
Mailing Address (Number and Street)

Date of Employment
From:
____________________
To:

____________________
____________________
Employers Telephone

City, State and Zip Code

Job Title / Detailed Description of Responsibilities

2.

Name and Address of Employer

Employer
Mailing Address (Number and Street)

Date of Employment
From:
____________________
To:

____________________
____________________
Employers Telephone

City, State and Zip Code

Job Title / Detailed Description of Responsibilities

3.

Name and Address of Employer

Employer
Mailing Address (Number and Street)
City, State and Zip Code
Job Title / Detailed Description of Responsibilities

Date of Employment
From:
____________________
To:

____________________
____________________
Employers Telephone

API 570 - PAYMENT INFORMATION

MOHANAD ABDULRAHMAN HASHIM
Applicants Name: _________________________________________
Exam ID # (If previously assigned):

Cost

900 USD

PAYMENT INSTRUCTIONS

All payments must be made in United States currency.

Checks must be drawn on a U.S. bank. You are responsible for all taxes, banking or other service fees,
including all applicable withholding taxes. Applicants name(s) must be included on the check.
For payments by electronic transfer: (1) you are responsible for all electronic transfer, A.C.H. and banking fees
(be sure to add the fees to your payment); (2) for electronic payments not drawn on a U.S. bank a fifty-dollar
($50) handling fee must be added at the time payment is made.
Please include a copy of the wire / electronic transaction. Applicants name(s) must be included on
the transaction document.

Initial Certification Fee

Reschedule / Retest Fee

($350.00)
Late Penalties
Bank Fee (if wired)

Wire Transfer to:

Beneficiary Name
Name of Bank
Branch of Bank
Account Number
Swift Code
IBAN Code

TOTAL SUBMITTED

: LHirondelle Quality SAS

: Banque Laydernier
: Ferney Voltaire, France
: 04608 14472100200
: NORDFRPP
: FR76 1022 8046 0814 4721 0020 013

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