Form 45674 - Water / Wastewater Operator Certification Continuing Education Credit Report

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WATER / WASTEWATER OPERATOR CERTIFICATION

To ensure proper credit, the water and

CONTINUING EDUCATION CREDIT REPORT

wastewater approval number MUST be

submitted.

State Form 45674 (R / 10-95)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Training course approval number

WWT

Mail completed report to:

Water

Wastewater

Continuing Education Coordinator

PWS

(indicate either Drinking Water or Wastewater) Operator Certification

To ensure proper credit, complete

Indiana Department of Environmental Management

separate form for Drinking Water and

P.O. Box 6015

Contact hours earned

Wastewater.

Indianapolis, IN 46206-6015

INSTRUCTIONS: To ensure proper credit, print legibly.

This form must be completed in order for the attendee to get credit. Be sure to record certification number and class / grade for each certification for which you

are requesting credit.

Mail original to DEM at the above address (indicate either Drinking Water or Wastewater). Training provider must retain a copy for their records in accordance

with 327 IAC 8-12-7.1.

Since this is a form of attendance verification, it is requested that this form be distributed during the latter portion of the training session. No credit will be

considered when original signatures are not shown.

Name of certified operator

Address (number and street)

City

State

ZIP code

Telephone number

Check here if this is a change of address.

Title of training course:

Name of organization offering the course:

Number of contact hours approved for the course:

CREDIT APPLIED TO: