Psma Application For Training & Limited License printable pdf download

APPLICATION FOR TRAINING & LIMITED LICENSE: One form per trainee and make copies as needed.

Send form & payment to: PSMA, 4305 North Sixth Street, Suite A, Harrisburg, PA 17110 or fax to 717.238.9985

• 717.763.PSMA (7762)

Part I. Employer Declaration and Agreement—complete BEFORE training

The below identified Business (“Licensee”) hereby applies for a limited license to use the Onsite Wastewater Treatment System Inspection

Standards promulgated by the Pennsylvania Septage Management Association, Inc. and the National Onsite Wastewater Education and Research

Foundation, Inc. (“PSMA/NOF”). If granted, the license shall remain in effect only so long as the individual named in Part 2 of this Application,

or another employee, is a Certified PSMA/NOF Inspector, as defined in the Training Policies of PSMA/NOF and remains in the employ of the

below identified business; and only so long as the identified business identified in Part I remains a member of PSMA. The license shall

automatically expire when either of these conditions ceases to exist.

As the employer of a PSMA certified Onlot Wastewater Treatment System Inspector, Licensee agrees and pledges that Inspectors in its employ will

fully apply the Standards for every inspection that is presented or described to the client or any other party as constituting a “PSMA Inspection,”

or words to that effect. Licensee agrees and pledges to comply with the PSMA Code of Ethics (Code).

Licensee acknowledges that failure to fully and strictly apply the Standards, or to misrepresent them, or failure to comply with the Code can result in

decertification of the Inspector and expulsion from Association membership. Upon the approval of the Application by PSMA, Licensee will be legally

bound by these terms. The person executing this Part I certifies that he or she is authorized to bind the identified Business to the terms hereof.

Business Name:

Signed:

Date:

(Candidate’s employer if different from candidate. If same, then candidate signs here.)

Company Name

Trainee’s Name

Address

City

State

Zip

E-mail

Phone

Fax

SR1 Training – January 24, 2011

2011 PA Decentralized Wastewater Conference & Trade Show

If you have special

Marriott Lancaster at Penn Square

needs, please contact

25 S. Queen Street • Lancaster, PA 17603

the PSMA office at

717.763.PSMA.

Check Correct Fee:

SR1 PSMA Member Tuition (ATTENDING CONFERENCE) – $25.00

SR1 PSMA Member Tuition (NOT ATTENDING CONFERENCE) – $150.00

TOTAL AMOUNT ENCLOSED: $

Make check payable to PSMA

Credit Card:

Visa

MasterCard

Discover

Credit Card Number:

Exp. Date:

3-Digit Security Code:

Name on Card:

Signature:

DO NOT COMPLETE PART 2. YOU WILL COMPLETE PART 2 AFTER THE TRAINING AND BEFORE THE TEST.

Part II. Inspector Candidate Declaration and Agreement—complete AFTER training

If I become certified as an Onsite Wastewater Treatment System Inspector by PSMA/NOF, I agree and pledge to fully apply the Standards for

every inspection that I represent to the client or any other party as constituting a “PSMA Inspection,” or words to that effect. I agree and pledge to

comply with the PSMA Code of Ethics (Code). I recognize that failure to fully apply the Standards or comply with the Code can result in my

decertification and the revocation of my employer’s License to use the PSMA/NOF Standards. My signature signifies my acceptance and

agreement to be legally bound by the above pledges and agreement.

I certify that I have completed the necessary training on

and that I am, to the best of my knowledge and belief, eligible to

complete the certification exam.

Signed:

(Candidate’s signature at completion of training)