Form 12094 - Public Water Supply Application For Water Treatment Plant And Water Distribution System Operator - Indiana Department Of Environmental Management Drinking Water Branch
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1
2
3FOR OFFICE USE
PUBLIC WATER SUPPLY APPLICATION FOR
WS number:
WATER TREATMENT PLANT AND WATER
DISTRIBUTION SYSTEM OPERATOR
Receipt number:
CERTIFICATION
State Form 12094 (R5 / 11-03)
Approved by State Board of Accounts 2003
Approved:
327 IAC 8-12-1
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
DRINKING WATER BRANCH
Denied/Reason:
NOTE:
A $30 fee must be submitted with each application for certification.
Applications must be signed by the individual, and his/her supervisor. Failure
to file a properly completed application may result in the application being
disapproved. (THE APPLICATION FEE IS NONREFUNDABLE)
This is an application for Grade: (check one - One application per grade checked):
PWS ID #:
Water Distribution System
Operator
DSS
DSM
DSL
Water Treatment Plant
Northwest
Central
Southeast
Operator
WT1
WT2
WT3
WT4
WT5
WT6
O.I.T
Northeast
Southwest
By examination
By reciprocity
PART I: GENERAL INFORMATION (please type or print legibly)
1.
Name of applicant (last):
(first)
(middle)
Mr.
Mrs.
Ms.
2.
Mailing address (number and street):
City:
State:
ZIP code:
County:
3.
4.
Office telephone number:
Home telephone number:
(
)
(
)
5.
Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeat/retake?)
Yes*
No
*If yes, date (dd/mm/yy):
6.
Are you presently a certified water works operator in Indiana?
Yes*
No
*If yes, give certification number and classification:
7.
Are you presently a certified water works operator in another state?
Yes*
No
*If yes, give certification number and classification (attach a copy of certificate)
8.
Have you ever had a certification suspended or revoked?
Yes
No
9.
Social Security number:*
*Your Social Security number is being requested by this state agency in order to expedite
processing of your application. Disclosure is voluntary and you will not be penalized for refusal.
PART II: EDUCATION AND TRAINING (applicants must have a high school diploma or GED)
10.
Check the highest grade completed.
Grade School:
High School:
College (years):
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
More than 6 years
1
11.
Date of graduation (dd/mm/yy):
Name and location of school
:
High School Graduate?
Yes
No
GED
12.
Degree:
Major:
College Graduate?
Yes
No
Date granted (mm/dd/yy):
Name and location of college:
(Continued on page 2)
1
Proof of education must be submitted when used as a substitution for experience.
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