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Public Water Supply Application For Water Treatment Plant And Water Distribution System Operator Certification 12094 - Indiana
| Public Water Supply Application For Water Treatment Plant And Water Distribution System Operator Certification Form. This is a Indiana form and can be used in Water Department Of Enviromental Management Statewide . |
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PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR CERTIFICATION State Form 12094 (R6 / 2-06) Approved by State Board of Accounts 2006 327 IAC 8-12-1 FOR OFFICE USE WS number: Receipt number: Approved: Denied/Reason: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH NOTE: A $30 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. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one - One application per grade checked): Water Distribution System Operator Water Treatment Plant Operator By examination DSS WT1 DSM WT2 DSL WT3 WT4 WT5 WT6 O.I.T PWS ID #: PLEASE CHECK EXAM LOCATION Northwest Northeast Central Southwest Southeast By reciprocity PART I: GENERAL INFORMATION (PLEASE TYPE OR PRINT LEGIBLY) (middle) 1. 2. City: 3. Name of applicant (last) Mr. Mrs. Ms. Mailing address (number and street): (first) State: Office telephone number: 4. ZIP code: Home telephone number: County: 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeat/retake?) Yes* No *If yes, date (mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? Yes* No *If yes, give certification number and classification: 7. Are you presently a certified water works operator in another state? Yes* No *If yes, give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? Yes No *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. 9. Social Security number:* PART II: EDUCATION AND TRAINING (APPLICANTS MUST HAVE A HIGH SCHOOL DIPLOMA OR GED) 10. Check the highest grade completed. Grade School: 1234 High School: 9 10 11 College (years): 1234 5 6 7 8 12 5 6 1 More than 6 years 11. High School Graduate? Yes No GED 12. College Graduate? Yes No Date granted (mm/dd/yyyy): Date of graduation (mm/dd/yyyy): Name and location of school : Degree: Major: Name and location of college: (Continued on page 2) 1 Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com PART II: EDUCATION AND TRAINING (CONTINUED) 13. Training courses, short courses, or other courses attended applicable to water industry: a. Name of course: Dates: College units or class hours: Name of school: b. Name of course: Dates: College units or class hours: Name of school: PART III: EXPERIENCE HISTORY (CURRENT/PREVIOUS EMPLOYERS) List your current assignment first. Show all experience in the Drinking Water field. Attach additional sheets, if necessary. DATE (Month and Year) FROM: TO: POSITION TITLE AND JOB DUTIES Position title: EMPLOYER NAME / ADDRESS Name of current employer: Specific duties performed in day-to-day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address: (number and street) City, state, ZIP code: (Continued on page 3) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com PART IV: TO BE COMPLETED BY CERTIFIED OPERATOR I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge. I have supervised this individual for years. Certification Number(s): Name of Certified Operator under whose supervision experience obtained Signature of Certified Operator: Printed name and signature of applicant's supervisor: (if different than above) Applicant's supervisor: (if different than above) Name of organization/utility/system: Telephone number: (include area code) Address: (number and street) City: State: ZIP code: PART V: SIGNATURE OF APPLICANT I, the undersigned, certify that I am the above applicant; that all statements made and information contained in the above application 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, or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied. Signature of applicant: Date (mm/dd/yyyy): The completed application, along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office, Mail Code 50-10C 100 North Senate Avenue Indianapolis, IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com
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