State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity Page 3

Download a blank fillable State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity 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 State Form 47290 - Application For Wastewater Treatment Plant Operator Certification By Reciprocity 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 misrepresentation 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)

The completed application, along with all required fees and attachments should be mailed to:

Cashier

Indiana Department of Environmental Management

100 North Senate

P.O. Box 7060

Indianapolis, Indiana 46207-7060

Please make all checks payable to the Indiana Department of Environmental Management.

DO NOT SEND CASH.