Nebraska Bridge Inspector Certification Approval Form

Name:	Mailing Address: (include City, State, and Zip Code)
Phone No.: (include Area Code)	Cell Phone No.: (include Area Code)
Employer:	Email Address:

Professional Engineer: Yes No	License Number and State:
Engineer Intern: Yes No	(Attach a copy of the Certificate)

Bridge Safety Inspection Experience (NBIS): (years) (Attach a sheet, explain in detail, give two references.)

Bridge Design, Construction, and Maintenance Experience: (years) (Attach a sheet, explain in detail, give two references.)

Bridge Inspection Training

Bridge Inspectors Training Course – Safety Inspection of In-Service Bridges (NHI 130055) (Attach a copy of the certificate.)

(2-week course) Yes No Date:

Fracture Critical Inspection Techniques for Steel Bridges (NHI 130078) (Attach a copy of the certificate.)

(3½-day course) Yes No Date:

Bridge Inspection Refresher Training (NHI 130053) (Attach a copy of the certificate.)

(3-day course) Yes No Date:

Other Training and Dates:

All training, certifications, and experience must be verifiable.

Bridge inspectors in the State of Nebraska will be identified on inspection reports using an inspector identification number consisting of the first letter of their first and last names followed by the last 4 numbers of their Social Security No. (example: TH1234).

Inspector ID:

Signature	Date

NDOT Form 97, July 17