State Form 12094-Application For Water Treatment Plant And Water Distribution System Operator Certification-Indiana Department Of Environmental Management Drinking Water Branch Page 2

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III. EXPERIENCE HISTORY

List your current assignment first. Show all experience in the Drinking Water field. Positions of responsible charge should be listed separately. Show any

related experience you feel is applicable.

DATE

POSITION TITLE

(Month and Year)

NAME ADDRESS OF PREVIOUS EMPLOYER

AND

JOB DUTIES

FROM:

TO:

Position title

Name of previous employer

Street address

Specific duties (Duties you perform in day to day operation, listing the various duties individually and

specifically. List additional experience on supplemental sheets)

City, state, ZIP code

Position title

Name of previous employer

Street address

Specific duties (Duties you perform in day to day operation, listing the various duties individually and

specifically. List additional experience on supplemental sheets)

City, state, ZIP code

Position title

Name of previous employer

Street address

Specific duties (Duties you perform in day to day operation, listing the various duties individually and

specifically. List additional experience on supplemental sheets)

City, state, ZIP code

TO COMPLETED BY APPLICANT’S SUPERVISOR

I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge.

I have supervised this individual for

years.

Signature of Supervisor

Certification number

Date (month, day, year)

Printed name of Supervisor

Title

Name of organization

Address (number and street)

Telephone number (include area code)

Address (city, state, ZIP code)

IV. SIGNATURE OF APPLICANT

I, the undersigned, certify that I am the above applicant; that all statements made and information contained in the above application are true and correct to

the best of my knowledge and belief; that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for, or

revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied.

Signature of applicant

Date (month, day, year)

The completed application, along with all required fees and attachments should be mailed to:

Cashier

Drinking Water Branch

Indiana Department of Environmental Management

100 North Senate

P.O. Box 7060

Indianapolis, Indiana 46207-7060

Please make all checks payable to the Indiana Department of Environmental Management.

(3240-4114-00-140000)