NAHAD Hose Safety Institute Application

This application form must be completed in its entirety. Incomplete applications will cause a delay in review.
An application update will be emailed to the Primary Contact within five-days of receipt after the Level 1 review, verifying NAHAD membership and active HSI certification(s) has been completed. At that time membership is provisional until the level 2 review is complete. As part of the review process, we will refer to our database for recent HSI Handbook purchases and team member completion of HSI certification and/or Fabrication courses/exams. You may also be asked to provide date-stamped photos to verify responses and show compliance.
Company Information:
Main Company Name:
Location Co. Name (if different)
Location Address:
City:
State/Province:
Zip/Postal Code:
Country:
Telephone:
HSI Point of Contact for this location:
Name:
Title:
Email Address:
Phone:
Hose Type Specialty for this location:
Hydraulic Hose
Industrial Hose
Composite Hose
Corrugated Metal Hose
Fluoropolymer Hose
End Markets Served:
Agricultural Machinery OEM
Agricultural Machinery Aftermarket
Automotive OEM
Automotive Aftermarket
Construction Machinery OEM
Construction Machinery Aftermarket
Food & Beverage
Forestry
General Maintenance, Repair and Operations (MRO)
Government (excluding Military)
Heavy-Duty Truck OEM
Heavy-Duty Truck Aftermarket
Industrial Machinery OEM
Industrial Machinery Aftermarket
Life Sciences (medical, pharma, etc)
Marine
Military
Mining
Oil & Gas
Power Generation
Process
Semicon
Other
Explain how you meet the requirements for HSI Membership:
Who at this location has successfully completed the HSI certification course/exam within the last three years?
Name
Email
Who at this location has successfully completed the appropriate HSI Fabrication course/exam within the last three years?
Name
Email
Explain how your organization uses S.T.A.M.P.E.D in the sales and fabrication process.
Check the testing methods employed:
Hydrostatic Proof Pressure Testing
Hydrostatic Burst Pressure Testing
Leak Testing
Helium Mass Spectrometer Testing
Electrical Continuity Testing
Electrical Dissipative Testing
Vacuum Testing
Impulse Testing
Elongation Testing
Other
Do you maintain an accurate and up-to-date record of regularly-scheduled calibrations for associated testing equipment?
Please provide clear and concise responses to the following questions:
Detail your Company Safety Plan. Include a summary of your company’s overall philosophy; SOP on the timing and audit process for handling incident reports; SOP for proper handling and storage requirements for chemicals and other hazardous materials.
What is your standard protocol for hose and hose assembly testing?
Provide detail of your hose tagging and identification protocol.
Explain how completed hose assemblies are packaged and stored.
Certifications/Training
Detail below, in list format, the distributor certifications achieved, and the certifications/training required of your assembly personnel:
Continental STAR Distributor
Eaton Aeroquip® Level 200 Certified
Dixon Hose Coupling Workshop
Parker Circle of Safety Training
ISO Certified
3A Certified Fabrication
Other (please specify)
Other (please specify)
References
Manufacturers will provide one Customer recommendation. This recommendation can be from a Distributor. Distributors will provide one Manufacture reference.
Manufacturer:
Company Name
Contact Name
Email Address
Phone Number
Customer:
Company Name
Contact Name
Email Address
Phone Number

Attestations & Acknowledgements
I attest that information provide as part of the HSI application process is truthful and can be verified through inspection.
I acknowledge that an annual attestation of compliance will be required upon renewal.
I understand that the HSI membership fee is due each January 1 after this initial first year.
Membership Fee:
$300 per location
The dues year runs from January 1 – December 31. Dues are renewable by December 31.
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