0159e-Engineers Declaration and Resume - CWB Group

CANADIAN WELDING BUREAUDIVISION OF CWB GROUP - INDUSTRY SERVICESCompany Code:CWB FORM 159E/2005-1Engineer's Declaration and ResumeName:Mailing AddressTelephone:Fax:Email:This declaration will confirm that I have been designated by:Name of Company/Plant/Division to Which Certification AppliesAddressto be responsible forto be responsible forwelding related activities as specified in CSA Standard W47.1orWelding Design Welding Procedures and Practice as specified in:CSA Standard W47.2 DivisionCSA Standard W186 orCSA Standard W55.3I amretainedemployed full time by the above company.For acceptance, engineers must meet the relevant requirements specified in Clause 6 of CSA StandardW47.1 or Clauses 4 and 5 of CSA Standard W47.2 or Clause 8.2.1 of CSA Standard W186 or Clause 3.1(a)of CSA Standard W55.3, as applicable.SignatureDATE (MM / DD / YYYY)Note: 1.2.Engineers who have not been previously accepted to the applicable standard must alsocomplete side 2 and provide the required supporting documentation.Submit an additional form, if designated for more than one standard.FOR CWB USE ONLY:First time review for this engineer:If yes, also complete CWB Form 640YesNoRegistrar:DATE (MM / DD / YYYY)Page 1 of 2

I am a Registered Professional Engineer in:CWB FORM 159E/2005-1EDUCATION:UniversityFaculty & Major Area of StudyDegree ObtainedYear ofGraduationI have successfully completed courses of study in the following subject areas (attach documented proof):Structural DesignFractureMachine DesignCorrosionWelding FundamentalsDesign of welded joints and connectionsBasic MetallurgyWelding MetallurgyWeld FaultsMethods of Quality ControlWelding Processes, Equipment & MaterialsInfluence of imperfections and acceptance criteriaWORK EXPERIENCE (As a minimum list all employers over the past 5 years)Name of Employer(List most recent employer first)FromToMM YYYY MM YYYYPresentTitle or PositionDescribe all relevant welding related work experience. Include all experience related to welding proceduredevelopment, welding inspection, welding design, weld failure investigations, practical welding experience,welding related courses, etc. Provide dates if applicale. Attach additional sheet if required.Page 2 of 2