Form Mde/wma/bww/oit - Application For Operator In Training (Temporary) Certificate
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1
2APPLICATION FOR
OPERATOR IN TRAINING (TEMPORARY) CERTIFICATE
This notice is provided pursuant to State Government Article, § 10-624, Maryland Code Annotated. The personal
information requested on this form is intended to be used in processing your application. Failure to provide the
information requested may result in your application not being processed. You have the right to inspect, amend, or
correct this form. The Maryland Department of the Environment (“MDE”) is a public agency and subject to the Maryland
Public Information Act. This form may be made available on the Internet via MDE’s website and is subject to inspection
or copying, in whole or in part, by the public and other governmental agencies, if not protected by federal or State law.
(Please Print or Type All Information except Signatures)
I: GENERAL INFORMATION:
Name: __________________________________________ Social Security Number:_________________________
Address: _______________________________________________________ City: __________________________
State: ____________________________Zip:______________________Telephone:__________________________
Email Address: _________________________________________________________________________________
Please provide the following information if you hold any other certificates issued by the Board of Water
And Wastewater Systems Operators:
Certificate No ___________ Expiration date______________________________
Category and Class of Certificate Applied For (Circle Below)
Wastewater Treatment (W)
1
2
3
4
5
6
S
A
Water Treatment (T)
1
2
3
4
5
G
(For Water 5 write RO, DE, Arsenic or GWUDI)
Industrial Wastewater (I)
1
2
3
4
5
6
7
Wastewater Collection (C)
1
2
Water Distribution (D)
1
II: EMPLOYMENT INFORMATION (to be completed by employer)
Name of the Facility: ________________________________________ Telephone: ____________________________
Street Address: ___________________________________________________________________________________
City _______________________________ State _________________________ Zip Code ______________________
MDE/WMA/BWW/OIT
Page 1 of 2
Revision Date (10/14)
Recycled Paper
TTY Users 1-800-735-2258
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Parent category: Business