APPLICATION FOR MACHINE WELDING
OPERATOR AND REPORT ON CERTIFICATION
AND PERFORMANCE QUALIFICATION
AB-70 2014-05
APPLICATION
A.
I,
(Full Name in Block Letters)
of,
(Address in Full)
Date of Birth (YYYY/MM/DD)
Home Telephone Number:
Business Telephone Number:
do hereby make application to undertake examination for a Machine Welding Operator's Certificate under The Safety Codes Act and
Regulations.
B.
I am employed by:
(Name of Organization)
C.
I am the holder of the following Welder's Certificates:
PROVINCE
D.
(Address of Organization)
CLASS AND No. OF CERTIFICATE
FILE NUMBER
I have had experience as a Welder or Welding Operator with the following Companies:
of
for
months
of
for
months
(Signature of Applicant)
(Date)
Approved for Examination
(Date)
(Safety Codes Officer)
(Date)
PERFORMANCE QUALIFICATION TEST
Qualification Information
Test Results
Base Metal Spec.
to P. No.
Material P. No.
Guided Bends
Test Coupon Thickness
Face Bends
Filler Metal Specification
Root Bends
Diameter of Test Coupon
Side Bends
Process(es)
RT or UT Results
Other
Tests/Remarks
Deposited Weld Metal
Coupon
No.
Pass
Fail
Filler Metal (F.No.)
Position(s) Tested
Performance Qualification Test Held At:
A Performance Qualification Test Card
(has)
(has not)
been issued. (See Note)
Details of Performance Qualification when Certificate is issued: FEE $242.00
Card No.
Process
Material (P.No.)
Invoice or
Receipt
Minimum
Max Deposited
Weld Metal
Pipe Dia.
Filler Metal Group
(F No.)
(Date of Test)
Position(s) Qualified
(Date of Expiry)
(Safety Codes Officer)
Please Print Name beside signature
Note: Please forward the completed Form and Performance Qualification Card to the ABSA Edmonton Office
FOR OFFICE USE ONLY
Assigned FILE NO. MW -
Administrator/Chief Inspector
Date
(Date)