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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

OFFICE OF WATER RESOURCES

APPLICATION FOR CLASS I, II, & III OWTS DESIGNER’S LICENSE EXAM

FOR DEM USE ONLY

Date Received_________________

Check No._____________

Amt. Received____________

Code 17B

INSTRUCTIONS

Read all instructions and questions carefully before completing this application.

Do not write in the box above labeled “For DEM Use Only”.

All information must be printed in ink or type written.

Fill out all sections completely, including your signature.

Attach a photograph to the application where indicated.

Include the non-refundable application fee of $50.00. Fees should be paid by check or money order made payable to GENERAL TREASURER, STATE OF RHODE ISLAND.

Send application and fee to: Department of Environmental Management, Office of Management Services,

235 Promenade Street, Providence, RI 02908.

Within 30 days of receipt of an application, the applicant shall be notified of their eligibility status. If the applicant is deemed ineligible, the Department shall provide the applicant with reasons for the

determination. The applicant may appeal the Director's decision of ineligibility with the Administrative Adjudication Division.

GENERAL INFORMATION

D.O.B._____/_____ / ________

PHOTOGRAPH

Attach unmounted

______________________________________________________________________________

recognizable photograph in

Last Name

First Name

this space with face not

more than 1 inch and not

less than ¾ inches wide.

______________________________________________________________________________

Photo must be taken not

Legal Mailing Address

more than six months prior

to filing application.

______________________________________________

( _______ )_____________________

City

State

Zip

Telephone

TAXPAYER CERTIFICATION

You are required to furnish your Social Security # or FEIN pursuant to Chapter 75 of Title 5 and Chapter 3 of Title 31 of the RI General Laws, as amended. Any person applying for any license or

permit to conduct a business or occupation within Rhode Island or any person renewing a motor vehicle operators license or motor vehicle registration within Rhode Island must have filed all

required state tax returns and paid all taxes due the state or must have entered into a written installment agreement to pay delinquent state taxes that is satisfactory to the Tax Administrator. Failure

to provide the Department with your Social Security # or FEIN will result in you having to obtain a Letter of Good Standing from the RI Division of Taxation One Capitol Hill Providence, RI 02908

(401) 222-6281, Collections Division PRIOR to the issuance or renewal of your license.

I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have either paid all taxes due the state or have entered into a written installment agreement

with the Rhode Island Division of Taxation.

Social Security # or FEIN ___________________________ Applicant’s Signature _____________________________________________________________________ Date _________________

Printed Name _____________________________________________________________________________

If necessary, please submit Letter of Good Standing or Installment Agreement along with this completed license application as directed above in the Instructions section of this

application form.

PRE-QUALIFICATIONS

Check exam for which you are applying (check one exam only) and provide applicable license information:

(To apply for an exam, you must hold at a minimum, the license indicated next to the exam for which you are applying.)

Class I

RIDEM OWTS Installer #__________

Class II

RI PLS #____________

Class III

RI PE #___________

Indicate additional license(s) held as appropriate

RIDEM OWTS Installer #____________

RI PLS #____________

*RI PE #_____________

NOTE to PEs: If you registered in Rhode Island after December 31, 1994 you must be registered as a Civil or Environmental Engineer. If applicable, indicate

the area of specialty.

Civil

Environmental

Revised January 2009