Registration for Medical Gas Training Seminar Please fill out a separate form for EACH student. "*" indicates required fields Red Lion MedGas Consultants, Inc.Registration for Medical Gas Training Seminar* ASSE 6005 Medical Gas System Specialists ASSE 6010 Medical Gas Systems Installer ASSE 6020 Medical Gas Inspector ASSE 6040 Medical Gas Maintenance Personnel Class Start Date:*Name of Student* First Last NicknameAddress of Student* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work PhoneHome or Cell Phone*Email* Social Security Number (Last 4 Digits)*Experience Level* Master Plumber Journeyman Apprentice N/A Years Experience*Job Title* Field Supervisor Inspector Estimator Other In-house hospital personnel (please specify)Current METC License Number (if any)StatesDo you currently work on medical gas pipelines?* Yes No Are you familiar with NFPA 99?* Yes No Name of Employer*Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Company Phone*FaxAcknowledgements* I certify that I have been involved with the mechanical trade for four years.
