Application For Soil Evaluator License Exam Form - Rhode Island Department Of Environmental Management Page 2

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PREREQUISITES (check appropriate box)



9 Semester Hours

Professional Soil Scientist

(Provide registration # below and attach copy of certificate)

SSSSNE Registration #_______________________

ARCPACS Registration #______________________

Have you ever possessed a professional license or certificate, which is related to soil science or OWTS design work, which was revoked, suspended or which has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__________________________.

EDUCATION

Provide copies of diplomas and/or college transcripts.

YEARS ATTENDED

EDUCATIONAL

DATE OF

NAME & ADDRESS OF INSTITUTION

DEGREE GRANTED

BACKGROUND

GRADUATION

From

High School

Technical School

College/University

List course titles which are to be applied towards the required 9 semester hours in soil science and provide transcripts or grade reports.

Title: __________________________________________________________________________________________________________Credits/Sem. hrs.: ______________

Date Completed: ______/______/______ Institution: _________________________________________________________________________________________________

Title: __________________________________________________________________________________________________________Credits/Sem. hrs.: ______________

Date Completed: ______/______/______ Institution: _________________________________________________________________________________________________

Title: __________________________________________________________________________________________________________Credits/Sem. hrs.: ______________

Date Completed: ______/______/______ Institution: _________________________________________________________________________________________________

EXAMINATION



Please check the components(s) of the examination for which you are applying

FIELD

WRITTEN

NOTE

NOTE: The written and field examinations do not have to be passed concurrently. However, if more than three years elapse before both components of the exam are passed,

the portion of the exam which was originally passed, must be retaken.

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

type “OWTS Licensing Exam Schedule” in the search window and the locations at which you may access the schedule and other information related to

the OWTS Professional Licensing Program will be returned. Schedule information may also be obtained by calling the OWTS Program at 401-222-4700.

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 July 2016