Form 44663 - Application For Wastewater Treatment Plant Operator-In-Training Certification - State Of Indiana

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APPLICATION FOR WASTEWATER TREATMENT

FOR OFFICE USE ONLY

PLANT OPERATOR-IN-TRAINING CERTIFICATION

Classification:

State Form 44663 (R / 4-99)

Approved by State Board of Accounts 1999

Status:

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

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

Remarks:

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

application being disapproved. (Application Fee Nonrefundable)

I. GENERAL INFORMATION (Please Type or Print Legibly)

A. Name (last, first, middle)

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

Office telephone number

Home telephone number

(

)

(

)

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

C. Date of birth

Yes

E. Are you presently a certified wastewater operator in Indiana?

If yes, give certification number and classification

Yes

II. EDUCATION AND TRAINING

A. High School graduate:

Date of graduation:

Circle highest grade completed

Yes

GED

Name and location of school

If no, circle highest year completed

B. College graduate:

Degree

Date granted

Major

Yes

Name and location of college

C. Training course, short courses or other courses in wastewater field attended:

1. Name of course:

Dates

College units or class hours

School

2. Name of course:

Dates

College units or class hours

School

3. Name of course:

Dates

College units or class hours

School

(Additional sheets may be attached as necessary)

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

NAME OF FACILITY, CLASSIFICATION OF FACILITY,

Month and Year

POSITION TITLE & JOB DUTIES

TYPE OF TREATMENT, AND

FROM

AVERAGE FLOW

Classification of Facility -

(Continued on reverse side)