AUTHORIZATION AND RELEASE FORM

Please print all of the following information:

SOC.SEC.#:______/______/______

NAME:___________________________________________________________

(First Name) (Middle Initial) (Last Name)

ADDRESS:________________________________________________________

(Mailing Address) (City) (State) (Zip Code)

HOME PHONE NUMBER:__________________________________________

(Area Code) (Phone Number)

EMPLOYER:______________________________________________________

(Write in name of company that pays you)

JOB SITE:_________________________________________________________

(Write in plant name that you are currently working in)

OCCUPATION/JOB CLASSIFICATION:______________________________

AUTHORIZATION & RELEASE

I, the undersigned, do hereby authorize Operator Qualification & Certification Center, L.P to release the information and results attained through the administering of the National Craft Assessment and Certification Program to the company referenced above, and acknowledge that said company is my present employer.

I, also, do hereby release (Company name)____________________________________, its representatives and its associating entities from any and all liability that may result from the release of this information. I further agree to hold harmless Operator Qualification & Certification Center, L.P, its representatives and associating entities from any and all damages for liability therefore which may result from the release of said information.

__________________________________ ___________________________

(Signature of Craft Worker) (Date)

__________________________________ ___________________________

(Signature of Witness/Proctor) (Date)