FOR OFFICE USE PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR CERTIFICATION WS number: Receipt number: State Form 12094 (R6 / 2-06) Approved by State Board of Accounts 2006 327 IAC 8-12-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH NOTE: Approved: Denied/Reason: 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 DSS By examination WT2 WT3 PWS ID #: PLEASE CHECK EXAM LOCATION DSL WT1 Water Treatment Plant Operator DSM WT4 WT5 WT6 O.I.T Northwest Northeast Central Southwest Southeast By reciprocity PART I: GENERAL INFORMATION (PLEASE TYPE OR PRINT LEGIBLY) 1. Name of applicant (last) Mr. Mrs. Ms. 2. (middle) Mailing address (number and street): (first) State: City: ZIP code: 4. County: Home telephone number: 3. Office telephone number: 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeat/retake?) Yes* 6. Are you presently a certified water works operator in Indiana? Yes* 7. *If yes, give certification number and classification: *If yes, give certification number and classification (attach a copy of certificate) No Have you ever had a certification suspended or revoked? Yes 9. No Are you presently a certified water works operator in another state? Yes* 8. *If yes, date (mm/dd/yyyy): No No 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. PART II: EDUCATION AND TRAINING (APPLICANTS MUST HAVE A HIGH SCHOOL DIPLOMA OR GED) 10. Check the highest grade completed. Grade School: 1 2 3 4 5 6 7 8 High School: 9 10 11 12 College (years): 1 2 3 4 5 6 More than 6 years 1 11. High School Graduate? Yes No GED Date of graduation (mm/dd/yyyy): Name and location of school : 12. College Graduate? Yes No Degree: Major: Date granted (mm/dd/yyyy): 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: b. College units or class hours: Dates: Name of school: College units or class hours: Name of course: 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: Address: (number and street) Specific duties performed in day-to-day operation: City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Address: (number and street) Specific duties performed in day-to-day operation: City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Address: (number and street) Specific duties performed in day-to-day operation: City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Address: (number and street) Specific duties performed in day-to-day operation: 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. Name of Certified Operator under whose supervision experience obtained Certification Number(s): 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) State: City: 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