Date:___________________________________

Contractor:_______________________________________________________

Address:_________________________________________________________

City, State, Zip Code:_______________________________________________

Phone Number:___________________________

Welder’s Name:____________________________________________________

Weld Process Last Date Welded

SMAW (stick) ________________________

GTAW (manual tig) ________________________

Welder ID Number:__________________________________________________

Signature:__________________________________________________________

(Contractor Representative)

Mailing or Fax Address:

Attention: Mike Warren

St. Paul Pipefitters L.U. 455

Saint Paul College

235 Marshall Avenue

Saint Paul, MN 55102

Phone: 651-253-2684

Fax: 651-846-1302