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UNITED ASSOCIATION

MEDICAL GAS INSTALLER

CERTIFICATION PROGRAM

U.A. LOCAL 501 AUTHORIZED TEST FACILITY

CONTINUITY INQUIRY

 

IT IS THE SOLE RESPONSIBILITY OF THE MEMBER TO HAVE THIS FORM COMPLETED BY THE EMPLOYING CONTRACTOR AND RETURNED WITH A CHECK 

IN THE AMOUNT OF $21.50 TO THE ADDRESS LISTED BELOW 

ON OR BEFORE THE CERTIFICATION DATE. 

 

LOCAL 501 JOINT EDUCATION FUND

1295 BUTTERFIELD RD.

AURORA, IL  60502

 

PLEASE MAKE YOUR CHECK OUT TO LOCAL 501 JOINT EDUCATION FUND. 

 

YOUR CERTIFICATION WILL NOT BE RENEWED IF PAYMENT IS NOT RECEIVED.

 

CONTRACTOR________________________________________________________________

PHONE NUMBER______________________________________________________________

INSTALLERS’ NAME___________________________________________________________

UA#____________________________________________

DATE BRAZING PROCESS WAS LAST USED _____________________________________

 

SIGNATURE_______________________________________________________

CONTRACTOR REPRESENTATIVE

DATE _____________________________________________________________

Office Use Only

Check Number ________________