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Superpave.psu.edu

CONCRETE RETEST
2014 APPLICATION FORM
Registration can be done using this form, OR on-line at
Please read and follow these directions. INCOMPLETE APPLICATIONS WILL NOT BE
CONSIDERED FOR REGISTRATION.

1. Fill in or attach information as indicated and obtain required signatures when noted.
2. Submit by mail a separate copy of this form for each applicant for each retest to
NECEPT at the address below. Check or money orders must be included for the
corresponding total fee payable to Pennsylvania State University. Credit card payments
are accepted only if paid on-line (i.e. through on-line registration).
If you register on-
line you MUST pay with a credit card; you may not mail in a check or money order
separately.
3. Applications that are not complete or are not accompanied with payment will be returned to the sender. (Note: All PennDOT employees will automatically be direct billed to the
appropriate PennDOT District unless payment is enclosed with this application.)
4. The applicant can attend the retest after a confirmation of payment and registration is received from NECEPT via e-mail. Therefore, you must enter a valid e-mail address.
More than one e-mail address may be listed if you would like multiple people to receive
the confirmation letter and directions to the course location and hotel information.
5. Once the applicant has received confirmation for registration and payment, NECEPT will provide the instructor’s contact information and the applicant will be responsible for contacting the instructor and setting up a retest date. 6. The applicant has the option to cancel up to 10 business days before the retest date and is eligible for a full refund less a $15.00 processing fee. The cancellation must be in writing and must be received by NECEPT ten business days before the deadline. Refunds for emergency circumstances will be considered on a case-by-case basis. There will be no refunds for applicants failing to contact the Instructor within 90 days of the original test date. 7. Applicant should allow 3 to 5 weeks after taking the retest to receive their certificate of completion and certification card.
8. ALL RETESTS MUST BE COMPLETED AFTER 30 DAYS, BUT WITHIN 90
DAYS OF THE ORIGINAL TEST DATE! Failure to complete your retest within the
90-day time frame will result in having to attend the Concrete Certification Course again.
9. The applicant may attend a maximum of two (2) PennDOT Certified Concrete Technician courses and take a maximum of one (1) retest per NECEPT training season. Falsification of information on this form may jeopardize your certification status.
NECEPT Contact Information:
Penn State/Larson Transportation Institute; NECEPT/PENNDOT Technician Certification Program CONCRETE RETEST
2014 APPLICATION FORM
BEFORE YOU FILL OUT THIS FORM READ THE PRECEDING PAGES

What is the NECEPT ID Number that you tested with? _______________

If you do not know this number please call (814) 863-1293 BEFORE you submit your application.
What was the date/location of your previous test? _______________________________________

Concrete Certification Retest
Applicant Name: _______________________________________________________
Email Address(s) for Course Confirmation : You must enter at least one e-mail address.

1. _______________________________
2. _______________________________
Affiliation: PENNDOT (District) ______ Industry ______ Consultant ______ Other (please specify)______
Company/Agency ____________________________________ Job Title __________________________
Home Address ___________________________________ City _______________ State ___ Zip _______
Daytime Phone ____________________________ Home Phone ____________________________
FAX number ____________________________

_____________________________ Printed Name of Supervisor _______________________________Signature of Supervisor


For information regarding course cancellation or rescheduling due to inclement weather, call 814-863-1293 or visit

BEFORE YOU MAIL THIS FORM, MAKE SURE YOU HAVE COMPLETED THE FOLLOWING.

 Enclose payment.  Fill in the form completely including obtaining signature from your current supervisor. If you are unemployed please write unemployed in the signature blank.

Source: http://www.superpave.psu.edu/training/5%20-%20Concrete%20Retest%20App_Revised%2010-7-13.pdf

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