State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity

Download a blank fillable State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

APPLICATION FOR WASTEWATER TREATMENT PLANT

FOR OFFICE USE

OPERATOR CERTIFICATION BY RECIPROCITY

Classification

State Form 47290 (R / 8-96)

Approved by State Board of Accounts 1995

Status

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Location

NOTE: A $30.00 fee must be submitted with each application for certification. Applications must be

signed by the individual, and his / her supervisor. Failure to file a properly completed application may

result in the application being disapproved. (APPLICATION FEE IS NONREFUNDABLE)

School

Remarks:

This is an application for a Class: (circle one)

Industrial

A-SO

Municipal

I-SP

III

Would you accept a lower classification if not eligible for Class circled above?

Yes

I. GENERAL INFORMATION (Please type or print legibly)

A. Name of applicant (last, first, middle)

Mr.

Mrs.

Ms.

B. Mailing address (number and street, city, county, state and ZIP code)

Office telephone number

Home telephone number

(

)

(

)

* Your Social Security number is being requested by this state agency in order

C. Date of birth

Social Security number *

to expedite processing of your application. Disclosure is voluntary and you will

not be penalized for refusal.

E. In which state are you presently certified?

D. Have you ever applied for wastewater certification in Indiana before?

Yes

Please give certification number and classification:

II. ABC RECIPROCITY REGISTRY

Are you presently listed on ABC's Reciprocity Register?

If Yes, what certification level?

Yes

Class I

Class II

Class III

Class IV

Certification number

III. EXPERIENCE HISTORY

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

any related experience you feel is applicable.

DATE

POSITION TITLE

NAME OF FACILITY, CLASSIFICATION OF FACILITY,

(Month and Year)

AND

TYPE OF TREATMENT AND AVERAGE FLOW

JOB DUTIES

TO:

FROM:

Position title

Name of facility