Form Mde/wma/bww/sup - Application For Superintendent Certification
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2APPLICATION FOR SUPERINTENDENT 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 ABOUT THE APPLICANT:
Name: __________________________________________ Social Security Number:____________________________
Address: _______________________________________________________ City: ____________________________
State: ___________________________________Zip:__________________Telephone:__________________________
Email Address: ___________________________________________________________________________________
II. APPLICANT'S CERTIFICATION INFORMATION:
Certificate number is: _______________ List Certificates currently held: ____________________________________
Operator: ____________________________________ Superintendent: ______________________________________
Has any state licensing or disciplinary board, or a comparable body in the Armed Services, denied your application to
renew or reinstate a license, or taken any action against your license including, but not limited to: reprimand, suspension
or revocation?
Yes ___
No ___
(If Yes, please attach an explanation.)
III. INFORMATION ABOUT THE APPLICANT'S EMPLOYER:
Name: __________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
City: ___________________________________________ State: _____________________
Zip Code: _________
Telephone: ___________________________
MDE/WMA/BWW/SUP
Page 1 of 2
Revision Date (10/14)
Recycled Paper
TTY Users 1-900-735-2258
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