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State Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination

FOR OFFICE USE

Classification

APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR

CERTIFICATION EXAMINATION

State Form 47289 (R5 / 2-08)

Status

Approved by State Board of Accounts, 2008

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Pursuant to 327 IAC 5-22

Remarks

NOTE: A $30.00 FEE MUST BE SUBMITTED WITH EACH CERTIFICATION EXAMINATION

APPLICATION. FAILURE TO FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN

THE APPLICATION BEING DISAPPROVED. APPLICATIONS ARE DUE NO LATER THAN 45 DAYS

PRIOR TO THE DATE OF THE EXAMINATION. (APPLICATION FEE IS NONREFUNDABLE.)

1. This is an application for: (check one)

Wastewater

Certified

Apprentice

Operator

2. Classification requested: (circle one)

Industrial: A-SO A B C D

Municipal: I-SP

I II III IV

3. If you are applying for Certified Operator, would you accept a lower operator

YES

classification if you do not currently meet the education and experience

requirements for your first choice? (circle one)

I. GENERAL INFORMATION FOR ALL APPLICANTS (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. Are you presently a certified operator in Indiana?

Expiration Date:(month,day,year)

Certification Number:

Yes

II. EDUCATION AND TRAINING-Must be completed for certification applicants, optional for apprentice applicants

List below all high schools and post high schools attended.

Diploma (GED) or Type of

Name/Location of School

To (month/year)

From (month/year)

Degree and Date of Graduation

High Sch. Grad?

Yes

College Grad?

Yes

Other:

If you are applying for Class IV / Class D certification, original transcripts must be enclosed. For the consideration of using college

education to substitute for work experience, original college transcripts must be enclosed.

If you would like to have your original transcripts returned, please check the box and enclose a self-addressed, stamped envelope.

Specialized Training or Classes Relevant to Certification

Dates Attended

Credits or Contact Hours

Title of Specialized Training or Class

Company/School Attended

(month,day,year)

earned:

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

"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 47289 - Application For Wastewater Treatment Plant Operator Certification Examination

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