Form 45674 - Public Water Supply Drinking Water Operator Continuing Education Credit Report
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1To ensure proper credit, the Indiana
PUBLIC WATER SUPPLY DRINKING WATER OPERATOR
Drinking Water approval number
CONTINUING EDUCATION CREDIT REPORT
MUST be submitted on this form.
State Form 45674 (R3 / 4-07)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
DRINKING WATER BRANCH
Indiana Drinking Water Approval Number
*The information in this document is confidential according to 327 IAC 8-12-7.6
“PWS_______________”
Mail
Indiana Department of Environmental Management
Maximum Credit Hours
to:
OWQ Drinking Water Branch - Mail Code 66-34
100 N. Senate Avenue
Indianapolis, IN 46204-2251
INSTRUCTIONS: To ensure proper credit, print legibly
This form must be completed in order for the attendee to get credit. Be sure to record the certification number and class/grade for each
certification for which you are requesting credit.
Mail the original form to IDEM at the above address. The Training Provider must retain a copy of the completed form for their records in
accordance with 327 IAC 8-12-7.6.
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
Mailing address (number and street):
City:
State:
ZIP code:
Work telephone number:
(
)
Home 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 DRINKING WATER:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Operator certification number:
Class/Grade:
Expiration Date:
Date Attended: (Required)
Location attended:
Number of contact hours attended and verified: (Required)
Signature of instructor or training provider: (Required)
Signature of drinking water operator: (Required)
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