Anne Rossborough #003-5597

Qualification Summary

• NDT Level II – UT

• Eye Exam

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Certification of Personnel Qualification

Employee Name: Employee ID #:

Testing Method: Certification Date:

Certification Level: Expiration Date:

Continuing Performance Evaluation(approx. mid-point of 5 yr duration) Date:

Formal Education Summary (Formal Education attained and claimed for qualification)

Education Location Date

Technical Training Summary (Documentation exists which verifies that the above individual meets or exceeds the qualification

requirements, in accordance with the written practice of this company.)

Course Location Date Lab Hours Hours

1.1.2013 80 80

80 80

Work Experience Summary (The following is a summary of the qualifying work experience claimed for this method by the above

Individual, and verified by this company.)

Employer Position Hire Date Hours Months

6.1.13 1,200 22

9.1.15 500 3

1700 25

Examination

General: 91% Specific: 72% Practical: 92% Composite: 85%

Recertification Practical:

Certification

Level: Verified By:

Date of Initial Certification: Certified By:

Statement:

I, the undersigned verify that all information contained on the Certification of Personnel Qualification form of the

above individual is true. The examination scores, dates, names and signatures of qualified examiners listed on

these forms were taken from the original or copies of the original documents.

1.7.16

Date

1.7.16

Date

SGS NDT Level II

NDT Level II UT Thickness

Ridgewater College

Ridgewater College Willmar, Minnesota 5.17.13

Ultrasonics

Lake of the Woods High School Baudette, MN 1986

Anne Rossborough

Ultrasonic Testing

Level II

CF Temp.003

1.7.16

1.31.21

Totals:

11627 Virginia Plaza, Suite 103, LaVista, NE 68128

Printed Name

TitleSignature - Company Representative

Signature - Authorized NDT Level III

Total:

II

1.7.16

Michael J. Sullivan

Michael J. Sullivan

Group Leader - NDT

Michael J. Sullivan

LMT

VISION EXAMINATIONS

Anne Rossborough AMR-5597 xxx-xx-5597 Applicant’s Name Certification No. Social Security No.

1. Near-Vision

Meets without eye correction

Meets with eye correction

Does not meet

Jaeger Number 2 or equivalent at a distance of not less than 12 inches

2. Color Perception

Meets without Eye correction

Meets with

eye correction

Does not meet

Red/green differentiation

Blue/yellow differentiation

I, certify that I, ____Michael J. Sullivan_______________, administered an eye exam Printed Name of Eye Examiner

to ___Anne Rossborough_______, on______1.7.16 which demonstrated Printed Name of Applicant Mo. Day Year the vision capabilities indicated above. * Required upon initial certification and annually thereafter. ______________________________________ Signature of Eye Examiner

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