Application for Certification - Interlocking Concrete Pavement Institute

Application for Certification Concrete Paver Installer Certification By submitting this form you are applying for ICPI Concrete Paver Installer Certification, and are verifying that you meet the first two requirements for certification:  

Attended the ICPI Concrete Paver Installer Course Earned a passing score on the certification exam

Once your installation experience has been verified, you will receive your certification document from ICPI. A certification term is two years. Applicant Information: (please list the contact information of the person applying for certification) ___________________________________________________________________________

Name (Please print) (Required)

___________________________________________________________________________

Company

___________________________________________________________________________

___________________________________________________________________________

Email (Required)

Phone

By signing below, you are verifying the following: 1. The installation experience listed on your application is accurate and represents your direct, onsite participation in the paver installation projects listed. 2. You are aware that 8 credits of continuing education must be earned, prior to your expiration date, within each two-year certification term. 3. You understand that your certification records might be randomly audited to verify installation experience and continuing education. Upon audit, if you cannot provide documented evidence of installation experience or continuing education, plus references for documented installation experience, you understand that your certification is subject to suspension and possible revocation. __________________________________________________________________________

____________________

Applicant’s Signature (required)

Date

List the following amount of installation experience. minimum of 5 projects and a minimum of 10,000 sq. ft. For example: • 2 projects totaling 20,000 sq ft does not meet the requirement • 9 projects totaling 8,000 sq ft does not meet the requirement • 5 or more projects totaling 10,000 sq. ft. or more does meet requirement

Important Notes:  Installation experience refers to active participation on-site in the construction of an interlocking concrete pavement system. Do not include any projects on which work has not yet begun, or for which you were not an on-site participant in the installation.  Installation experience can be taken from any period of time that a person has been installing. Installers can go back as many years as needed to fulfill the requirement.  This application needs to be submitted only once. You will not be required to submit this application again.  The Record of Completion received for passing the Concrete Paver Installer certification exam does not expire, so if you do not currently meet the minimum installation experience requirements, you can wait until you do meet them, and submit your application at that time.  References are only required if your certification record is audited. You may leave the last column blank for now if you wish. However, if references are not provided upon request, your certification is subject to suspension.

ID Number (ICPI office use only)

Please complete second page

List installation experience showing at least 5 projects and at least 10,000 sq. ft. Project Title or Type of Project

Location

Completion Date

(city, st/prov)

(YYYY-MM-DD)

Area (sq. ft.)

1

2

3

4

5

Total SQ. FT.: *ICP – Interlocking Concrete Pavement **PICP – Permeable Interlocking Concrete Pavement

___________

Copy this page if you need more space

Application

Market Segment

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

 ICP*  PICP**  Bitumen Set  Pedestal  Mechanical  ___________

 Industrial  Commercial  Institutional  Municipal  Residential

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Reference (not required at this time)

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Name: __________________ Phone: __________________ Additional Contact Info:

Email, Fax, or mail all pages of this form to ICPI. Email: [email protected] Fax: (703) 657-6901 Mail: ICPI, 14801 Murdock ST., Ste. 230, Chantilly, VA 20151