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Form 12094 - Public Water Supply Application For Water Treatment Plant And Water Distribution System Operator - Indiana Department Of Environmental Management Drinking Water Branch Page 3

PART IV: TO BE COMPLETED BY CERTIFIED OPERATOR

I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge.

I have supervised this individual for ________ years.

Name of Certified Operator under whose supervision experience obtained

Certification Number(s):

Signature of Certified Operator:

Printed name and signature of applicant's supervisor if different than above:

The applicant’s supervisor if different than above:

Name of organization/utility/system:

Telephone number (include area code):

Address (number and street):

City:

State:

ZIP code:

PART V: SIGNATURE OF APPLICANT

I, the undersigned, certify that I am the above applicant; that all statements made and information contained in the above application are true and

correct to the best of my knowledge and belief; that I understand that any omissions or misrepresentations may result in ineligibility for the

examination applied for, or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I

have applied.

Signature of applicant:

Date (mm/dd/yy):

The completed application, along with all required fees and attachments should be mailed to:

Cashier

Drinking Water Branch

Indiana Department of Environmental Management

100 North Senate Ave.

P.O. Box 7060

Indianapolis, IN 46207-7060

Please make all checks payable to the Indiana Department of Environmental Management

(3240-4114-00-140000)