1) There Are Quite a Few Qstis Whose Current Approvals Will Expire In

Qualified Source Testing Individual

Renewal Application Form

This application form applies only if you are an approved QSTI and applying for renewal. Once you have passed the test methods group exam(s) of your choice, please complete this QSTI renewal application package and send by email to or by mail to:

The Source Evaluation Society

P. O. Box 12124

Research Triangle Park, North Carolina 27709-2124

The information in this application will be treated as confidential by the SES Qualified Source Testing Individual and Qualified Source Testing Observer (QSTI/QSTO) review board. Please, type or print information except where signature is required. It is not necessary for you to send a separate renewal application for each group for which you apply but instead provide one combined renewal application and continued experience record. The SES QSTI/QSTO review board will consider each application on its merits and consistent with the criteria established for approving SES QSTIs.

General Information

Last name: ______First name: ______Middle initial: _____

SES QSTI Certificate Identification Number: ______

Title: ______

Organization name (check if changed from earlier application __ ): ______

Street address: ______or P. O. Box: ______

City: State: Zip: ______

Phone: ______E-Mail address: ______

Fax number: ______

Home Address(or other optional address; check if changed from earlier application):

Street Address: ______or P. O. Box: ______

City: State: Zip: ______

Phone: ______E-Mail Address: ______

This is my QSTI renewal application for Test Method Group(s) ______which I passed on ______[date(s)].

Continued experience record (check all that applies):

[ ]Conduct pre-test meeting with source owner or operator, testing organization) - approximate number conducted in last two years: ______

[ ] Develop and submit pre-test plans for approval -approximate number conducted in last two years: ______

[ ] Lead or conduct field sample collection operations - approximate number conducted in last two years: ______

[ ] Develop and review test reports (audit calculations, data validation, and results interpretation) - approximate number conducted in last two years: ______

[ ] Conduct sample recovery, handling, and custody operations - approximate number conducted in last two years: ______

[ ] Conduct quality assurance (e.g., auditing) and quality control measures for source emissions testing projects - approximate number conducted in last two years: ______

[ ] Conduct testing training for staff - approximate number conducted in last two years: ______

I hereby certify that the information contained in this application and on supporting documents attached to this application is correct to the best of my knowledge. I agree to indemnify and hold harmless the Source Evaluation Society, the SES QSTI/QSTO Review Panel, the SES Board of Directors, and all others affiliated with the SES and its programs.

Applicant's Signature: ______Date: ______

Revised 3/19/2014