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API 580Certification Program for Advanced Knowledge of Risk BasedInspectionApplication Instructions

1. This application is a writable PDF. Please make sure to download the application documentand save it on your computer. You can then open the application, type in your information,and print the application forms. (Any application filled in while viewing it online will not besaved, nor will it be sent to API electronically.) All applicationsmust be mailed to API.

2. Fill out all pages of this application completely.

3. Please enter your name as it appears in your passport / government-issued ID / driverslicense.

4. Please include your API ID number every place that your name appears in the applicationform.

5. You must include an Employment Confirmation Letter with the application. See Page 7 for fullinstructions. This requirement is waived for Inspectors who hold a valid certification in the API510, 570, or 653.

6. Read and sign BOTH Inspector Agreements

7. Include the certification fee. See Page 2 for ICP Financial Policies. We will not process anyapplication until full payment is received.

8. Be sure to keep a copy of the completed application that you mail to API.

9. When you have completed your application see checklist at the back of this packet to ensureyou have included all the information and documents necessary.

Be sure to include a unique and current e-mail address. All API correspondence will be sent to thee-mail address you provide.

The exam is closed book and questions are taken from theAPI RP 580 document. See the TestRegistration Form for the appropriate edition required. The publications for ICP certification examsmay be ordered through IHS (www.global.ihs.com) or TechStreet (www.techstreet.com)

INFORMATION FOR THE DAY OF THE EXAM:Youareallowedtohaveonlythefollowinginthetestroom :SharpenedNo.2pencils,aneraserandacalculator(simplefunctiononly,non-programmable).Anythingelsecouldbeconfiscatedbytheteststaff.

ICP FINANCIAL POLICIES

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Payment Policy

API cannot process any application until full payment is received. No exceptions will bemade under any circumstances. Candidates WILL NOT BE PERMITTED TO TAKE AN ICPEXAMINATION if payment has not been received AND processed by API. Proof of paymentmust be included with your application.

API must RECEIVE your ORIGINAL application by mail on or before the applicationdeadline.

All payments must be made in United States currency.

Paying by credit card provides the best opportunity to ensure that payment is receivedand processed by API in the timeliest manner.

Checks must be drawn from a US bank. You are responsible for all taxes, banking orother service fees, including all applicable withholding taxes.

If your company is going to pay the fee make sure they know the deadline and allowplenty of time for the company to make payment.

If paying by wire transfer please submit a copy of the electronic transaction documentwith your application. The applicants name MUST be included on the wire transactiondocument. If the copy is not included with the application please e-mail a copy [email protected] as soon as possible to allow time to identify the payment and scheduleyou for the exam.

Refund Policy

All requests for refunds must be submitted to API in writing by mail, e-mail or fax

and requested within 6 months of the date of the payment.

For refund requests made before the application deadline:

API will refund the initial certification fee less $100.00 for processing.

For refund requests made after the application deadline:

API will refund 50% of the initial certification fee. Reschedule fees are non-

refundable.

For refund requests made after the date of your examination:

No refunds will be issued whether you took the examination or not.

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API 580 Application Form Basic InformationCertification Program for Advanced Knowledge of Risk Based Inspection

New API Exam EXAM ID #(if previously assigned)

___________________________________________________________________________________________FIRST MIDDLE LASTNAME (please spell it the same way as it appears on your passport / drivers license)

Home Address (Number and Street) Date of Birth (Month / Day / Year)

City, State and Zip or Postal Code Home Telephone Number

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

Employer Data Work Telephone Number

Employer Business Email (Unique e-mail not shared)

Employers Address (P.O. Box or Number andStreet)

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 examorganizer, please include this persons e-mail here:

Country Group Contact E-mail

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Additional InformationAPI 580, Certification Program for Advanced Knowledge of Risk BasedInspection1. 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 foreach question.

At which address do you wish to receive your certificate? Home WorkAre you interested in being included in the on-line API InspectorDirectory, when you obtain your certification?

Yes No

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

2. Do you currently have an active API certification? Yes No

If yes, enter your certification number and expiration date. If youanswer yes, you need not complete the Education and Training Form.

Program / Certification Number Expiration Date



3. Are you currently a full-time, non-contract employee ofan 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 checkone box on each side.

Industry Organization type

PETROLEUM OWNER-USER

CHEMICAL INDIVIDUAL CONTRACTOR

PAPER/PULP INSPECTION COMPANY

SERVING ALL INDUSTRIES CONSULTING/CONSTRUCTION

OTHER OTHER

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

Full-time employee of an owner/user

Full-time employee of an inspection agency/other company

Independent contractor

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Education and TrainingAPI 580, Certification Program for Advanced Knowledge of Risk BasedInspectionPlease attach copies of your school / university diplomas.High School / Secondary School

Name Location Year Graduated

Name Location Year Graduated

Trade / Vocational SchoolName 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

Name Duration of Studies Major Degree Type Dates Attended



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Employment HistoryAPI 580, Certification Program for Advanced Knowledge of Risk BasedInspection(Last three employers or at least the last five years)1. Name and Address of Employer (Current) Date of Employment

EmployerFrom:

___________________

Mailing Address (Number and Street)To:

____________________

City, State and Zip Code ____________________Employers Telephone

Job Title / Description of Responsibilities

2. Name and Address of Employer Date of Employment

EmployerFrom:

____________________


____________________

City, State and Zip Code ____________________

Employers Telephone


3. Name and Address of Employer Date of Employment

EmployerFrom:

____________________


____________________

City, State and Zip Code ____________________Employers Telephone


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Verification Requirements for Employment HistoryEmployment Confirmation Letters

ll candidates must have their employers submit an Employment Confirmation letterthat will verify the years of experience and scope of activities that they have

performed while under employment. If there are multiple employers to meet theminimum requirement, you must have each of the employers submit a letter.

The letter must be submitted on company letterhead, and signed by a company official suchas HR/department manager, director, or vice-president. The letter must confirm the following:

Name of applicantDates of employmentJ ob Title of the candidateDetails of the job responsibilities

Please Note: This requirement is waived for Inspectors who hold a valid certificationin the API 510, 570 or 653.

Please be sure to attach the letter of employment confirmation.

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API 580 Test RegistrationApplicants Name: _________________________________________Exam ID #(If previously assigned):

Examination Locations and Dates

Please indicate your preferred exam date and location listed below.

September 25, 2013(Application Deadline API must receive no later than July 10, 2013)

(AfternoonExamSession)Application deadlines are firm no exceptions will be made.

North America:

Anchorage, AK Edmonton, AB (Canada) Oakland, CA

Atlanta, GA Houston, TX Oklahoma City, OK

Baton Rouge, LA Indianapolis, IN Philadelphia, PA

Corpus Christi, TX Los Angeles, CA

Other Locations:

Abu Dhabi, UAE Chennai, India Kuala Lumpur,

Malaysia

Safat, Kuwait

Al-Khobar, Saudi Arabia Chia, Colombia Mumbai, India Singapore, Singapore

Cairo, Egypt Doha, Qatar Port of Spain, Trinidad United Kingdom(Contact API for city info)

If a location of your choice is not listed above please contact API for more information.

If you are testing at an API-approved special site, please include the location and/or

group here:_________________________________________City, Country

> > THIS FORM MAY ALSO BE USED TO RESCHEDULE A TEST

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10. The Inspector agrees to comply strictly with all U.S. export laws relating to this program. The Inspector warrantsthat he is not located in, or under the control of, or a national or resident of any embargoed countries.

11. This agreement shall not and is not intended to benefit or to grant any right or remedy to any person or entity that isnot a party to this Agreement.

12. This instrument contains the entire and only agreement between the parties. No oral statements or representationsnot herein contained shall have any force and effect.

13. Paragraphs 2, 3, 4, 5, 6, 7, and 8 survive termination of this agreement.

14. It is expressly understood between the parties hereto that no association, agency, apparent agency,employer/employee relationship, partnership, or joint venture of any kind has been created. Inspector agrees not torefer to himself as APIs agent nor refer to the relationship between the parties as a joint venture or partnership or in

any manner inconsistent with this Agreement. Inspector shall have no authority to act or contract on behalf of API.

15.No waiver by API of any default, misrepresentation, or breach of warranty or covenant hereunder, regardless ofwhether intentional, shall be deemed to extend to any prior or subsequent default, misrepresentation, or breach of

warranty or covenant hereunder or affect in any way any rights arising by virtue of any prior or subsequent suchoccurrence.

16. API makes no express or implied warranties regarding the ICP program or potential benefits of the certification to theInspector.

17. The Inspector agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by any

government body or authority in any way measured by this Agreement, or any portion of it, or any services relatedthereto.

18. Inspector understands and agrees that Inspector is not granted any rights under the program or this Agreement untilAPI has determined that the Inspector has satisfied all of the program requirements and has issued a Certificate to theInspector. The Inspectors certification shall be effective on the date that is noted on the Certificate and shall beeffective for a period of three years unless terminated pursuant to the terms of this Agreement.

19. This Agreement shall be governed by and construed in accordance with the laws of the District of Columbia, USA,without regard to the rules regarding conflicts of law. The parties agree that any action, suit, or proceeding basedupon any matter, claim, or controversy arising hereunder or relating hereto shall be brought exclusively in the federal

or state courts located in District of Columbia, USA. The parties consent to the jurisdiction and venue of such courts,and waive any objections to the jurisdiction and venue thereof.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agree to complywith the conditions specified above.

Applicants name (please print) _____________________________ E-mail: _________________________

___________________________________ _________________

Signature of Applicant Date

Applicants address: ______________________________________________

______________________________________________

API Reviewers Initials: ____________

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Inspector Application Agreement - 2(for Initial and Renewal Certification)(Effective upon Receipt of Application)The applicant agrees to the following conditions:

1. API agrees to evaluate the applicants qualifications to determine if the Inspector satisfies the requirements of the ICPprogram. Applicant understands and agrees that: (1) API will not issue an ICP certificate to the Applicant unless APIdetermines that an Applicant meets all of the requirements and Applicant has submitted the applicable fees anddocumentation within the specified time frame, and (2) API shall be the sole judge of whether the Applicant has theappropriate qualifications to become certified, remain certified, or be recertified.

2. The Applicant agrees to pay the applicable fees, comply with all of the program requirements and submit anysupplemental information or documents deemed necessary by API to verify an applicants qualifications. Applicantunderstands and agrees that API does not represent or warrant that the submission of the fees and materials by theApplicant will result in the Applicant being certified under the program.

3. Each new application remains valid for a period of 12 months from the date of receipt by API. API grants eachapplicant three attempts during the 12-month period to sit and pass the test, starting with the first exam administrationthe applicant registers for. Applicants must pass the exam within these three exam administrations. If an applicant fails

to appear for the test, cancels his/her appearance and reschedules, or takes the exam and fails it, it will count as an

official attempt.

4. If the applicant does not obtain a certification within this period of time and still wishes to obtain the certification, theymust start the application process again, including re-submission of a full fee and a complete new application.

5. All requests for refunds must be submitted in writing by mail, e-mail or by fax to API no later than 6 months from thedate payment was received by API. Requests for refunds received after this period cannot be fulfilled.

6. An applicant is entitled to a full refund of the application fee, minus a processing fee, only if API receives the refundrequest prior to the exam application deadline.

7. An applicant is entitled to a 50% refund of the application fee if the refund request is received by API within 6 monthsfrom the date payment was received by API and the candidate cancelled in advance of the examination date.

8. No refunds will be made if an applicant has taken the test or did not show up without prior notice.

9. For normal processing API must receive recertification applications prior to the current certifications expiration date.Recertification applications must be mailed, as API requires the original of the notarized page.

10. API may extend the certification term for 3 (three) months after the expiration date. Inspectors will remain authorizedduring that period of time. Recertification applications received by API within this extension term will be processed,but a $150.00 late fee will be required.

11. Inspectors who do not apply for recertification within three months after the current certification expiration date will bedecertified.

12. Circumstances such as heavy work schedule or work in other countries do not relieve the applicant of the responsibilityto file a timely renewal application.

13. Applicant understands and agrees that API may modify the requirements for an applicant to obtain, maintain, or renewthe certification at any time. If APIs requirements are modified, API shall determine the date by which the new

requirements become effective. Applicant agrees to comply with the modified requirements within the deadlinespecified by API. API agrees to attempt (but assumes no duty) to notify Applicant of significant changes to the

program by either giving notice: ( (1) the Applicants last known e-mail address, or (3) by posting the changes on theAPI website. It is the responsibility of the Applicant to notify API of address changes. The failure of API to notifyApplicant of a renewal date or modification of the program does not relieve the Applicant of the responsibility to file atimely renewal application or to comply with new certification requirements. It is the responsibility of the Applicant toobtain this information by contacting API or by checking the API website.

14. The Applicant agrees to comply strictly with all U.S. export laws relating to this program. The Applicant warrants thathe is not located in, or under the control of, or a national or resident of any embargoed countries.

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15. The Applicant agrees to pay all sales, use, property, excise, and other taxes now or hereafter imposed by anygovernment body or authority based on in any way measured by this Agreement, or any portion or it, or any servicesrelated thereto.

16. Applicant warrants and represents to all information that is being submitted pursuant to this is complete and accurate.Applicant understands that API is relying upon the accuracy of this information in evaluating the Inspectorsqualifications. Applicant agrees to indemnify API for any claims, losses, or damages resulting from the Applicantsubmitting inaccurate or misleading information.

I, the undersigned, certify that I have read and fully comprehend this form in its entirety and agreeto abide by the policies and regulations specified above.

Applicants name (please print) ____________________________ E-mail: ___________________________

___________________________________ _________________

Signature of Applicant Date

API Reviewers Initials ________________

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API 580 - PAYMENT INFORMATIONApplicants Name: _________________________________________Exam ID #(If previously assigned):API member rate applies to full-time, non-contract employees of API-member companies.

API Member Non Member

$225.00 $275.00

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 includedon the transaction document.

PAYING BY CREDIT CARD CAN EXPEDITE THE PROCESSING OF YOUR APPLICATIONAND PAYMENT TO ENSURE YOUR PLACE IN THE EXAMINATION.

Credit Card Type: Visa American Express MasterCard

Card Number: Expiration Date:

Name as it appears on card _____________________________________________

Signature_______________________________________ Initial Certification Fee

E-mail address to send receipt:Reschedule / Retest Fee

($75.00)

Check Late Penalties

Bank Fee (if wired)

Wire Transfer to:TOTAL SUBMITTED

TD Bank1030 15th St NWWashington, DC 20005 USA

ABA Routing #054001725Credit to: American Petroleum InstituteAccount #4251303172SWIFT: NRTHUS33

(Reference: Applicants Name and SS-2100-D9200-7110)

Your application will not be processed if this page is not completed.

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CHECKLIST

1. All pages of the application completed

2. Valid e-mail address included so we can contact you

3. Employment Confirmation letter (s) attached.

4. BOTH Inspector Agreement forms signed

5. Certification Fee (payment page filled in completely)

6. Copy of transaction documentation if paying by wire

7. Copy of completed application made for your records

MAIL ORIGINAL APPLICATION TO:

APIIndividual Certification Programs1220 L Street, NWWashington DC 20005

(Phone: 202-682-8064)Please include candidates name(s) on all payments.

IF PAYING BY CHECK OR MONEY ORDER, MAIL APPLICATION TO:APIIndividual Certification ProgramsP.O. Box 1425

Merrifield, VA 22116

TO SEND CHECKS BY COURIER, PLEASE ADDRESS PACKAGE TO:APIAttn: John Robertson1220 L Street, NWWashington, DC 20005Phone 202-682-8064

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