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

FOR OFFICE USE

Classification

APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR

CERTIFICATION BY RECIPROCITY

State Form 47290 (R4 / 2-08)

Status

Approved by State Board of Accounts, 2008

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Pursuant to 327 IAC 5-22

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

Remarks:

FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN THE APPLICATION BEING

DISAPPROVED. (APPLICATION FEE IS NONREFUNDABLE.)

PLEASE SUBMIT A COPY OF YOUR CURRENT CERTIFICATION ALONG WITH THIS APPLICATION

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

Industrial

A-SO

Municipal

I-SP

III

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

Yes

I. GENERAL INFORMATION (please type or print legibly )

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

Mr.

Miss

Mrs.

Ms.

B. Mailing Address (number and street ):

City:

State:

ZIP code:

County:

Office telephone number:

Home telephone number:

(

)

(

)

Fax number:

E-mail address:

(

)

D. Have you ever applied for wastewater certification in

C. Date of birth: (month,day,year)

Indiana before?

Yes

E. In which state are you presently a certified operator?

Expiration Date: (month,day,year)

Certification Number:

Did you obtain this certification by a written exam?

State Contact Person:

Yes

Mailing address (number and street):

City:

State:

ZIP code:

II. EDUCATION AND TRAINING

List below all high schools and post high schools attended.

Diploma (GED) or Type of Degree

Name/Location of School

To (Month/Year)

From (Month/Year)

and Date of Graduation

High Sch. Grad?

Yes

College Grad?

Yes

Other:

Specialized Training or Classes Relevant to Certification

Title of Specialized Training or Class

Company/School Attended

Dates Attended

Credits or Contact Hours

earned:

Copies of credit report forms or proof of attendance must be enclosed.

1 "Contact Hour" means a fifty (50) to sixty (60) minute instructional session, approved by the Commissioner and involving a qualified instructor or

lecturer. Ten (10) contact hours equals one (1) continuing education unit (CEU).

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

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