571_2013 (Revised2) 8

API 571 Test Registration Applicants Name: _________________________________________ Exam ID # (If previously assigned):

Examination Locations and Dates Please indicate your preferred exam date and location listed below.

September 25, 2013 (Application Deadline API must receive no later than July 10, 2013)

(MorningExamSession)Application deadlines are firm no exceptions will be made.

North America:

Anchorage, AK Edmonton, AB (Canada) Oklahoma City, OK

Atlanta, GA Houston, TX Philadelphia, PA

Baton Rouge, LA Los Angeles, CA St. Paul, MN

Corpus Christi, TX Oakland, CA

Other Locations:

Abu Dhabi, UAE Cairo, Egypt Kuala Lumpur, Malaysia

Singapore, Singapore

Al-Khobar, Saudi Arabia Chennai, India Mumbai, India United Kingdom (Contact API for city info)

Bogota, Colombia Doha, Qatar Port of Spain, Trinidad

If a location of your choice is not listed above please contact API for more information. If you are testing at an API-approved special site, please include the location and/or group here:_________________________________________ City, Country

> > THIS FORM MAY ALSO BE USED TO RESCHEDULE A TEST

571_2013 (Revised2) 13

API 571 - PAYMENT INFORMATION Applicants Name: _________________________________________ Exam ID # (If previously assigned): API member rate applies to full-time, non-contract employees of API-member companies.

API Member Non Member $225.00 $275.00

PAYMENT INSTRUCTIONS

All payments must be made in United States currency. Checks must be drawn on a U.S. bank. You are responsible for all taxes, banking or other service fees,

including all applicable withholding taxes. Applicants name(s) must be included on the check. For payments by electronic transfer: (1) you are responsible for all electronic transfer, A.C.H. and banking

fees (be sure to add the fees to your payment); (2) for electronic payments not drawn on a U.S. bank a fifty-dollar ($50) handling fee must be added at the time payment is made.

Please include a copy of the wire / electronic transaction. Applicants name(s) must be included on the transaction document.

PAYING BY CREDIT CARD CAN EXPEDITE THE PROCESSING OF YOUR APPLICATION AND PAYMENT TO ENSURE YOUR PLACE IN THE EXAMINATION. Credit Card Type: Visa American Express MasterCard

Card Number:

Expiration Date:

Name as it appears on card

_____________________________________________

Signature _______________________________________ Initial Certification Fee

E-mail address to send receipt: Reschedule / Retest Fee ($75.00)

Check Late Penalties

Bank Fee (if wired)

Wire Transfer to: TOTAL SUBMITTED TD Bank 1030 15th St NW Washington, DC 20005 USA ABA Routing # 054001725 Credit to: American Petroleum Institute Account # 4251303172 SWIFT: NRTHUS33 (Reference: Applicants Name and SS-2100-D9200-7110)

Your application will not be processed if this page is not completed.

September2013: OffAK: OffAB: OffOK: OffGA: OffHTX: OffPA: OffLA: OffCA: OffMN: OffTX: OffOCA: OffEGP: OffMAL: OffSING: OffSpecial Site Request: UAE: OffSA: OffIND: OffMIND: OffUK: OffCol: OffQA: OffTRIN: OffApplicants Name: ExamID: VIS: OffAmEx: OffMC: OffCheck Box16: OffWire: OffCard Number: Expiration Date_4: Name as it appears on card: Email receipt: Initial Certification Fee: Reschedule Retest Fee 7500: Check#: Late Penalties_2: Bank Fee if wired: TOTAL SUBMITTED: