Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination - Indiana Page 3

Download a blank fillable Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination - Indiana in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 47289 - Application For Wastewater Treatment Plant Operator Certification Examination - Indiana with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

V. SIGNATURE OF APPLICANT

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

charge are true and correct to the best of my knowledge and belief; that I have listed all potentially affected parties, as defined by IC 4-21.5, to the best of

my knowledge and if none are listed it signifies that none are known; that I understand that any omissions or misrepresentations may result in ineligibility for

the examination applied for, revocation of any certificate 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.

Signature of applicant

Date (month, day, year)

VI. SIGNATURE OF APPLICANT’S SUPERVISOR

I hereby certify the information contained in Section II and III 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

Name of organization