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State Form 44663 - Application For Wastewater Treatment Plant Operator-In-Training Certification

FOR OFFICE USE

Classification

APPLICATION FOR WASTEWATER TREATMENT PLANT

OPERATOR-IN-TRAINING CERTIFICATION

State Form 44663 (R2 / 2-04)

Status

Approved by State Board of Accounts - 2004

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Pursuant to 327 IAC 5-22

Remarks:

NOTE: A $30.00 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. APPLICATIONS ARE DUE NO LATER THAN 45 DAYS PRIOR TO THE DATE OF THE

EXAMINATION. (APPLICATION FEE IS NONREFUNDABLE.)

I. GENERAL INFORMATION (please type or print legibly )

A. Name of applicant (last, first, middle )

Mr.

Miss

Mrs.

Ms.

B. Mailing Address (number and street ):

City:

State:

ZIP code:

County:

Office telephone number:

Home telephone number:

(

)

(

)

Fax number:

E-mail address:

(

)

C. Date of birth:

D. Have you ever applied for wastewater certification in

Indiana before?

Yes

II. EDUCATION AND TRAINING

List below all high schools and post high schools attended.

Diploma (GED) or Type of Degree

Name/Location of School

To (Month/Year)

From (Month/Year)

and Date of Graduation

High Sch. Grad?

Yes

College Grad?

Yes

Other:

Specialized Training or Classes Relevant to Certification

Title of Specialized Training or Class

Company/School Attended

Dates Attended

Credits or Contact Hours

earned:

Copies of credit report forms or proof of attendance must be enclosed.

"Contact Hour" means a fifty (50) to sixty (60) minute instructional session involving a qualified instructor or lecturer. Ten (10) contact hours equals

one (1) continuing education unit (CEU).

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State Form 44663 - Application For Wastewater Treatment Plant Operator-In-Training Certification

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