Nace CP 1 - Page 20

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Form 1: Summary of Cathodic Protection Related Work Experience
Instructions: Make and use as many copies of this form as needed. Please provide all information requested.
Forms must be printed legibly in black ink or typed. Illegible information can delay the application process. For
assistance with this form, contact the Education Division at NACE International Headquarters.
Applicant Information:
Name: A. Sample
Phone: 409/111-4321
Company: ZZZ Coating Inspection Inc.
Fax: 409/111-1234
Address: 987 Gage Avenue
City: Millspec
State/Province: TX
Zip/Postal Code: 77987
Country: USA
Please summarize below the information on each copy of Form 2, Individual Job Documentation. List your
experience beginning with the most recent, followed by less recent experience.
From
Month/Year
To
Month/Year
Number of
Months in this
job
Job Title Company Name
1/92 1/95 36 CP pipeline
readings
ZZZ Gas Co.
12/89 12/91 24 Installer AAA Tank Installers
12/87 12/89 24 Design Manager ABC CP Design
/ /
/ /
/ /
/ /
/ /
/ /
/ /
Applicant Affidavit: I understand that if I knowingly provide false information in connection with my recognition
under this program, it will be grounds for disciplinary procedures.
Signed:
Date: