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State Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination Page 4

V. SIGNATURE OF APPLICANT (Required)

I, the undersigned, certify that I am the above applicant; that all statements made and information regarding education, training, acceptable

experience and responsible charge experience are true and correct to the best of my knowledge and belief; that I understand that any omissions or

misrepresentations may result in ineligibility for the examination applied for, revocation of any certification granted or voiding a decision made

regarding my application. I also consent to verification of my qualifications for the certificate for which I have applied.

Date (month, day, year)

Signature of Applicant

VI. SIGNATURE OF APPLICANT'S SUPERVISOR (Required for certification applicants, optional for apprentice)

I, the undersigned, hereby certify the information contained in Sections II, III, and IV of this application is true and correct to the best of my

knowledge.

I have supervised this individual for ____________ years.

Signature of Supervisor

Date (month, day, year)

Printed Name of Supervisor

Title

Wastewater Cert. Number, if applicable

Name of Organization

Address (Number and Street Name, City, State, ZIP Code)

Telephone number: (

)

Fax Number: (

)

The completed application, along with all required fees and attachments should be mailed to:

Cashier

Indiana Department of Environmental Management

100 N. Senate Ave - Mail Code 50-10C

Indianapolis, IN 46204-2251

Please make all checks payable to the Indiana Department of Environmental Management.

DO NOT SEND CASH.

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State Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination Page 4