Form Mde/wma/bww/rec - Application For Reciprocity Certification
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1
2APPLICATION FOR RECIPROCITY CERTIFICATION
MARYLAND BOARD OF WATERWORKS AND WASTE SYSTEMS OPERATORS
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)
I.
GENERAL INFORMATION:
Name:
Social Security Number:
Address:
City:______________________________
State:
Zip:
Telephone: ______________________
Email Address: ____________________________________________________________________________________
II.
CATEGORY AND CLASS OF RECIPROCITY APPLIED FOR
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
III. EDUCATION:
Yes [ ]
No [ ]
GED [ ]
High School Graduate?
Name of High School:
IV. CURRENT EMPLOYMENT INFORMATION:
Employer's Name __________________________________________________ Telephone: _________________________
Immediate Supervisor's Name_________________________________________ Telephone: ________________________
Name of the Facility:_________________________________________________Class:____________________________
___
MDE/WMA/BWW/REC
Revision Date (10/14)
TTY Users 1-800-735-2258
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Parent category: Business