State Form 12094-Application For Water Treatment Plant And Water Distribution System Operator Certification-Indiana Department Of Environmental Management Drinking Water Branch
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1
2PUBLIC WATER SUPPLY
FOR OFFICE USE
APPLICATION FOR WATER TREATMENT PLANT AND WATER
WS number
DISTRIBUTION SYSTEM OPERATOR CERTIFICATION
State Form 12094 (R4 / 1-00)
Receipt number
Approved by State Board of Accounts 1999
327 IAC 8-12-1 Edition 1996
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Approved
DRINKING WATER BRANCH
Denied
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)
PWS ID #
This is an application for Grade: (check one - One application per Grade checked)
Northwest
Central
Southeast
Northeast
Southwest
Water Distribution System Operator
DS
DSL
Water Treatment Plant Operator
CT
PF
GF
AT
By examination
By reciprocity
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. Have you ever applied for Water Works certification in Indiana before?
D. Are you presently a certified operator in Indiana?
Yes
No
Yes
No
If yes, date (dd/mm/yy)
/
/
/
If yes, give certification number and classification
E. Are you presently a certified operator in another state?
F. Have you ever had a certification suspended or revoked?
If yes, give certification number and classification (attach copy of
Yes
No
Yes
No
certificate)
G. Social Security number*
* Your 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.
II. EDUCATION AND TRAINING (applicants must have high school diploma or GED)
A. Check the
Grade school
1
2
3
4
5
6
7
8 High school
9
10
11
12 College
1
2
3
4
5
6
More than 6
highest grade
completed:
B. High school graduate?
Date of graduation:
Name and location of school: (Proof of education must be submitted when used as substitution for experience)
Yes
No
GED
C. College graduate?
Degree
Major
Yes
No
Name and location of college:
Date granted:
D. Training course, short courses or other courses in water field attended:
1. Name of course:
Name of school
Dates:
College units or class hours:
2. Name of course:
Dates:
College units or class hours:
Name of school
3. Name of course:
Name of school
Dates:
College units or class hours:
4. Name of course:
Name of school
Dates:
College units or class hours:
(1)
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