Application For Soil Evaluator License Exam Form - Rhode Island Department Of Environmental Management

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

OFFICE OF WATER RESOURCES

APPLICATION FOR SOIL EVALUATOR LICENSE EXAM

FOR DEM USE ONLY

Date Received_________________

Check No._____________

Amt. Received____________

Code 17B

INSTRUCTIONS

PHOTOGRAPH

1. Read all instructions and questions carefully before completing this application.

Attach unmounted

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

recognizable photograph in

3. All information must be printed in ink or type written.

this space with face not

4. Fill out all sections completely, including your signature.

more than 1 inch and not

5. Attach a photograph to the application where indicated.

less than ¾ inches wide.

Photo must be taken not

6. Include the non-refundable application fee of $50.00. Fees should be paid by check or money order made payable to:

more than six months prior

GENERAL TREASURER, STATE OF RHODE ISLAND.

to filing application.

7. 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

_______________________________________________________

________ /________ / ________

Last Name

First Name

Date of Birth

_______________________________________________________

Legal Mailing Address

Business Mailing Address

_______________________________________________________

City,

State

Zip

Business City,

State

Zip

( _______ )_____________________

( _______ )______________________________________________

Telephone

Business Telephone (with extension if applicable)

________________________________________________________________

Email Address

Business Email Address

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) 574-8941, 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.

EMPLOYMENT HISTORY

List relevant work experience in soil studies and percolation testing for septic system design in RI or in soil classification, mapping, interpretation or a combination thereof. DO NOT list unrelated

work experience. Attach additional sheets if necessary.

Current employment

Name of employer: ______________________________________________________________________________________ Position: _____________________________________________

Address:______________________________________________________________________________________________ Telephone: ___________________________________________

Date employed from:______________ to:_____________ total # of yrs. employed_________

Duties:______________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Past employment

Name of employer: ______________________________________________________________________________________ Position: _____________________________________________

Address:_______________________________________________________________________________________________ Telephone: ___________________________________________