Form Mde/wma/bww/oper - Application For Operator Examination Page 2
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2III. CURRENT EMPLOYMENT INFORMATION:
Employer's Name: _____________________________________________ Phone #: ______________________
Name of the Facility:__________________________________________________ Class: ___________________
IV. APPLICANT'S STATEMENT:
I hereby affirm that this application contains no willful misrepresentations or falsification and that this information given
by me is true and complete to the best of my knowledge and belief. I am aware that should an investigation at any time
disclose my misrepresentation or falsification, my application will be disapproved or my certification will be revoked.
Applicant’s Signature______________________________
Date_______________________________
PRIVACY POLICY
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.
NOTE: An incomplete application will be returned.
Make checks payable to: Maryland Board of Waterworks and Waste Systems Operators
Mail to: Maryland Department of the Environment, P.O. Box 2057, Baltimore, Maryland 21203-2507.
THE APPLICATION MUST BE RECEIVED BY THE BOARD AT LEAST 21 DAYS PRIOR TO THE
PREFERRED EXAMINATION DATE.
AOBJ: 5958 / 46031
MDE/WMA/BWW/OPER
Page 2 of 2
Revision Date (10/14)
Recycled Paper
TTY Users 1-800-735-2258
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