Free 51139.xls - Indiana

WASTEWATER OPERATOR/APPRENTICE CONTINUING EDUCATION CREDIT REPORT
State Form 51139 (R3 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

To ensure proper credit, the wastewater approval number MUST be provided. Training Course Approval Number: Technical Contact Hours Earned: General Contact Hours Earned:

Operator

Apprentice

INSTRUCTIONS: In accordance with 327 IAC 5-22-17(c), the training provider must submit this form within ninety (90) days of the conclusion of the wastewater treatment continuing education course. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Dept. of Environmental Management 100 N. Senate Ave - Mail Code 65-42 Indianapolis, IN 46204-2251 - Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM. - Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete wastewater treatment continuing education course. - The training provider must retain a copy of this form for their records for a three (3) year period following the presentation of each wastewater treatment continuing education course. - Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified operator/apprentice attending the entire wastewater operator continuing education course. CERTIFIED OPERATOR/APPRENTICE INFORMATION
1. NAME: 2. ADDRESS (number and street): City: State: ZIP code: Telephone number: Work: Home/Cell:

Check here if this is an address change 3. NAME OF TRAINING COURSE: 4. NAME OF TRAINING COURSE PROVIDER: 6. DATE(S) ATTENDED (month, day, year):

E-mail Address:

COURSE INFORMATION

5. NAME OF ORGANIZATION SPONSORING COURSE: 7. LOCATION ATTENDED:

8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATOR/APPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours:

9. CERTIFICATE OF COMPLETION IS REQUIRED FOR ALL ON-LINE COURSES. I, the undersigned, certify under penalty of law that this document (and any attachments) were prepared under my direction or supervision and that the information submitted is, to the best of my knowledge and belief, true, accurate, and correct. I also understand that any omissions or misrepresentations may result in the denial of continuing education credit for this course. 10. SIGNATURE OF INSTRUCTOR: 12. SIGNATURE OF CERTIFIED OPERATOR/APPRENTICE: 11. PRINTED NAME OF INSTRUCTOR: 13. PRINTED NAME OF CERTIFIED OPERATOR/APPRENTICE:

14. CONTINUING EDUCATION CREDIT HOURS ARE TO BE APPLIED TO: Operator certification/apprentice number: Class:

Expiration date:

Operator certification/apprentice number:

Class:

Expiration date: