WASHINGTON ASSOCIATION OF BUILDING OFFICIALS

SPECIAL INSPECTION REGISTRATION PROGRAM

KEY PERSONNEL REGISTRATION APPLICATION FORM

1. Applicant Information

Application For: Technical Director ($160) Supervising Laboratory Technician ($160) Special Inspection Field Supervisor

($160 1st type of work plus $55 each additional)

Applicant Name (last) (first) (MI)

Home Address

(city) (state) (zip)

Home Phone ( ) E-Mail

Are you 18 years of age or older? Yes No

Have you ever been convicted of a felony? Yes No (Note: A conviction will not necessarily bar you from registration.)

Agency Employer Name

Agency Location

Agency Phone Number ( )

2. Type(s) of Work For Which Applicant Is Seeking RegistrationKey personnel may become registered to direct or supervise any number of types of work. Check each typeof work you are applying for below:

Reinforced Concrete* Spray-applied Fire-resistive Materials

Prestressed Concrete** Lateral Wood

Shotcrete** Cold-Formed Steel Framing

Structural Masonry Proprietary Anchors

Structural Steel and bolting Fire-Resistant Penetrations and Joints

_____ Structural Welding

* Requires current ACI certification as an ACI Field Technician - Grade 1.** Reinforced Concrete registration is a prerequisite for obtaining this registration

3. Education and Training InformationNote: Information should relate to the type(s) of work for which the applicant is seeking registration.Merely referencing an enclosed resume is not acceptable. The list should contain specific education andtraining experience with relevant dates of each experience. Refer to Appendix C of WABO Standard No.1701 for creditable education and training experience. If additional space is needed, attach supplementalsheets.

4. Work Experience InformationNote: Information should relate to the type(s) of work for which the applicant is seeking registration.Merely referencing an enclosed resume is not acceptable. The list should contain specific education andtraining experience with relevant dates of each experience. Refer to Appendix C of WABO Standard No.1701 for creditable education and training experience. If additional space is needed, attach supplementalsheets.

5. Projects Experience ListNote: Information should relate to the type(s) of work for which the applicant is seeking registration. Thelist should include: the name of the project; the date(s) the applicant worked on the project, the name andtelephone number for the registered agency or the applicants supervisor on the project, the test and/orinspection methods and standards that the applicant was responsible for on the listed project, and thetype and size (number of stories) of each listed project. If additional space is needed, attach supplementalsheets.

6. Information Accuracy Certification and Inquiry ConsentI certify that all statements, answers and information given as part of this application process are accurateto the best of my knowledge. I understand that giving false and/or misleading information may be causefor rejection of this application or revocation of subsequent registration as a key personnel registrant.

I consent and authorize representatives of the Washington Association of Building Officials to request anyinformation concerning my previous employment, education, military service or other information pertinentto this application.

(Signature of Applicant) (Date)

Key Personnel Registration Bulletin R93-08

Applicant Name: Home Address: city: state: zip: EMail: Agency Employer Name: Agency Location: Date: Check Box233: OffCheck Box234: OffCheck Box235: OffText236: Text237: Text238: Check Box239: OffCheck Box240: OffCheck Box241: OffCheck Box242: OffText243: Check Box244: OffCheck Box245: OffCheck Box246: OffCheck Box247: OffCheck Box248: OffCheck Box249: OffCheck Box250: OffCheck Box251: OffCheck Box252: OffCheck Box253: OffCheck Box254: Off