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Application For Class I, Ii & Iii Owts Designer'S License Exam Form - Rhode Island Department Of Environmental Management Page 2

PRE-QUALIFICATIONS (continued)

Are any of the licenses checked on the reverse of this form currently expired, suspended, or revoked? Yes

Have you ever possessed a professional license, which is a minimum requirement to obtain a RIDEM designer’s license, which was revoked, suspended or

which has expired? Yes

If yes, what type of license _______________________________________________________.

If yes, please give date of revocation, suspension or expiration __________________________.

CURRENT EMPLOYMENT

Name of employer: _____________________________________________________________________________________________________________

Position: ______________________________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________________________

# Street

____________________________________________________________________________________________________________________________

City

State

Zip

(___________) ________________________

Telephone

EXAMINATION SCHEDULE

All OWTS licensing examinations are administered once annually. When the examination schedule is established, it is posted to the DEM website

. Select “Permits”, then “ISDS Designer/Installer Licenses”, then the link to the “Exam Schedule for OWTS Licensing”. Schedule

information may also be obtained by calling the OWTS Program at 222-4700.

AFFIDAVIT

I, the undersigned Applicant, hereby declare under the penalty of perjury that all statements made on this application and in support thereof are true and

complete to the best of my knowledge and belief; that this application is made in compliance with the laws, rules, and regulations of the State of Rhode Island.

Signature of Applicant_________________________________________________________________

Date____________________

Subscribed and sworn to before me this______________ day of ________________________________, 20_________.

Signature of Notary______________________________________________ My Commission expires_________, 20_______.

(SEAL)

Revised January 2009