American Welding Society 8658 NW 35 St, #130 Mor 33165-6572 (00) 443-3353 exenson 273 Email corfcation@aws.org Visuat Acuity FORM ] Member #: 247241 Email address: aulyuivan d ge, com pate: _o~ hig 202 Last Name: But First Name AU mi: VAN Applicant “This form mustbe submitted for al SCW/CWI/CAWI/CR/CWEng applications ONLY. "AWS Wl not ease exam ests, ecetfieaton results, or renewals without a completed Visual Acuity Record on He IMPORTANT: This completed Visuol Acuity Form must be sent tothe AWS Certification Department along withthe application. Applicants whe have ‘ot fulfiled oll requirements and/or have not submited the form, sll have test seures/applntion volded wl may bx In Jeopardy of forfeting application fors. This form may be sent va emall oF mall. Eye Examination ye examinations shall be administered by an Ophthalmologist, Optometrist, Medical Doctor, Registered Nurse or Certifies Physician's Assistant or by ‘ther ophthalmic medical personnel and must include the state or province icense number. Examinations shall be performed not more than one (1) ‘year prior tothe date of the certification examination or the expiration date for renewals and recertifiations. New visual acuity records do not need to be supplied for retests occuring within one (1) year from the original examination date ‘Allapplicants must pass an eye examination, with or without corrective lenses, to prove near vision acuity on Jaeger 12 at 12 in, or greater (230.5 em). ‘Allapplicans shal take a color perception test. Eye examination results must be documented on ths Visual Acuity Record form supplied by the AWS Certification Department. No other forms wil accepted, 4.The following must be completed by the eye examin« A. Verify the customer's close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater (230.5 cm) (Check ONLY on ofthe flowin foreach eve} 0 | o8 | [© |Requires corrected vision to read Jaegar J2 at 12 in. or greater. uw | 7 Io correevon's required to read Jaegar 12 112, LO greater. Unable to read Jaegar 12 at 12 in. or greater even with attempt at correction, 8 ©. Through a color perception examination s the applicant colorblind? {Check ONLY one ofthe folowing foreach eye) oo] I | LY customer ts Nor colorblind [1 TE leustomer 1s colobing. 3. Examiner's Contact information (gine) Customer Name: Blut VAN Atr Date nf eye exam: b fg. 202) Examiner Name: My DIN THEI HUONG Phone Number: 0944 Yoo 44 Examiner Address: No. 303 5 Vuong City: _Auary Ngai _ state ny Zip/Postal Code: _53 0000 Country: _\Vietnann 4. Examiner professional status checkonone) Clophthaimoosise CJ optome Difimedical Dowwr — ] Registered Nurse] certified Physician's Assistant State/Prov. Licensenumber: Joo ¢ . ~ is y Seung BCH - QS - QUANG NGAI Visual Acuity Form 1224 x8. Dinh Ghibo BENT XA B21 ‘it 18,2018 Examiner Signature: Li;