Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination - Indiana
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1
2
3APPLICATION FOR WASTEWATER TREATMENT PLANT
FOR OFFICE USE
OPERATOR CERTIFICATION EXAMINATION
Classification
State Form 47289 (R2/4-99)
Approved by State Board of Accounts 1995
Status
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Location
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 file a properly completed application may
result in the application being disapproved. (APPLICATION FEE IS NONREFUNDABLE)
School
Remarks:
This is an application for a Class: (circle one)
Industrial
A-SO
A
B
C
D
Municipal
I-SP
I
II
III
IV
Would you accept a lower classification if not eligible for Class circled above?
Yes
No
I. GENERAL INFORMATION (please type or print legibly)
A. Name of applicant (last, first, middle)
Mr.
Mrs.
Ms.
B. Mailing address (number and street, city, county, state and ZIP code)
Office telephone number
Home telephone number
(
)
(
)
C. Date of birth
Social Security number *
* Your Social Security number is being requested by this state agency in order
to expedite processing of your application. Disclosure is voluntary and you will
not be penalized for refusal.
D. Have you ever applied for wastewater certification in Indiana before?
E. Are you presently a certified wastewater operator in Indiana?
Yes
No
Yes
No
If yes, give certification number and classification:
II. EDUCATION AND TRAINING
A. High school graduate?
Date of graduation:
If No, circle the highest grade completed:
7
8
9
10
11
12
Yes
No
GED
Name and location of school:
B. College graduate?
Degree
If No, circle the highest year completed:
Major
Yes
No
1
2
3
4
Name and location of college:
Date granted:
If you are applying for Class IV / Class D or for college experience substituted for work experience, transcripts must be enclosed.
C. Training course, short courses or other courses in wastewater field attended:
1. Name of course:
Name of school
Dates:
College units or class hours:
2. Name of course:
Name of school
Dates:
College units or class hours:
3. Name of course:
Name of school
Dates:
College units or class hours:
Copies of credit report forms or proof of attendance must be included.
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