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Get CA Form 720-21 2015

MUST BE ON CONTRACTOR LETTERHEAD FEE 40. 00 Send to NITC 501 Shatto Place Suite 201 Los Angeles CA 90020 Office 877 457-6482 Fax 213 382-2501 RECORD OF CONTINUITY BRAZER QUALIFICATION FOR MEDICAL GAS VACUUM SYSTEMS We wish to use provision QB-322 of the ASME Section IX Boiler and Pressure Vessel Code Renewal of qualification of the performance qualification is required when a brazer or brazing operator has not used the specific brazing process for a period of 6 months or more or when there is a specific reason to question the ability to make brazes that meet the specification. We also wish to comply with the NFPA99 Health Care Facilities Code Performance qualifications of brazers shall remain in effect indefinitely unless the brazer does not braze with the qualified procedure for a period exceeding 6 months or there is a specific reason to question the ability of the braze. BRAZER NAME BRAZER STREET ADDRESS CITY STATE AND ZIP SOCIAL SECURITY or CARD I. D. XXX- - RESIDENCE PHONE / ID CELLULAR PHONE This individual has brazed using the qualified process and specific brazing procedure listed below. NITC BPS 13-BPS148 demonstrate the ability to make sound brazes. DATE OF MOST RECENT BRAZEMENT Must be on or before expiration date Note This individual s braze qualification will be extended six 6 months from the date entered above. BRAZER NAME BRAZER STREET ADDRESS CITY STATE AND ZIP SOCIAL SECURITY or CARD I. D. XXX- - RESIDENCE PHONE / ID CELLULAR PHONE This individual has brazed using the qualified process and specific brazing procedure listed below. NITC BPS 13-BPS148 demonstrate the ability to make sound brazes. DATE OF MOST RECENT BRAZEMENT Must be on or before expiration date Note This individual s braze qualification will be extended six 6 months from the date entered above. Sincerely Print Name of Contractor or authorized representative Individual that witnessed brazement Signature of Contractor or authorized representative Title of signer Name of Company Please refer to the NITC Website for current pricing www. BRAZER NAME BRAZER STREET ADDRESS CITY STATE AND ZIP SOCIAL SECURITY or CARD I. D. XXX- - RESIDENCE PHONE / ID CELLULAR PHONE This individual has brazed using the qualified process and specific brazing procedure listed below. NITC BPS 13-BPS148 demonstrate the ability to make sound brazes. DATE OF MOST RECENT BRAZEMENT Must be on or before expiration date Note This individual s braze qualification will be extended six 6 months from the date entered above. Sincerely Print Name of Contractor or authorized representative Individual that witnessed brazement Signature of Contractor or authorized representative Title of signer Name of Company Please refer to the NITC Website for current pricing www. nationalitc*com Method of Payment Total Amount Enclosed Check Money Order Credit Card No CVV2 Visa Master Card AMEX Expiration Date Last three or four digits on back of Visa and Master Card Amex CVV2 on front of card. Credit Card Billing Address Name on Card Signature As it appear on card Please Print Form 720-21 Rev 06-05-15 record of continuity. .

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