Free 53583.xls - Indiana

APPLICATION FOR WASTEWATER TREATMENT PLANT OPERATOR CERTIFICATION EXAMINATION - SHORT FORM for APPRENTICESHIP ONLY

FOR OFFICE USE Classification

State Form 53583 (4-08) Status Approved by State Board of Accounts, 2008 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Pursuant to 327 IAC 5-22 Remarks: NOTE: A $30.00 APPLICATION FEE MUST BE SUBMITTED FOR EACH EXAM. APPLICATIONS MUST BE SIGNED BY THE INDIVIDUAL. FAILURE TO FILE A PROPERLY COMPLETED APPLICATION MAY RESULT IN THE APPLICATION BEING DISAPPROVED. APPLICATIONS ARE DUE NO LATER THAN 45 DAYS PRIOR TO THE DATE OF THE EXAMINATION. (APPLICATION FEE IS NONREFUNDABLE.) Industrial: A-SO A B C D This is an application for Wastewater Apprentice only. You may Municipal: I-SP I II III IV apply for one Industrial and one Municipal exam. You must submit an application fee for each. Please circle exam(s) desired:

I. GENERAL INFORMATION (please type or print legibly )
A. Name of applicant (last, first, middle ) Mr. Miss Mrs. Ms. B. Mailing Address (number and street ) City Office telephone number ( ) Fax number ( ) C. Date of birth (month, day, year ) E. Are you presently a certified operator in Indiana? Yes No State ZIP code County

Home telephone number ( ) E-mail address D. Have you ever applied for wastewater certification in Indiana before? Yes No Expiration Date (month, day, year ) Certification Number

II. SIGNATURE OF APPLICANT
I, the undersigned, certify that I am the above applicant; that all information is 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, voiding a decision made regarding my application. Date (month, day, year ) Signature of applicant

The completed application along with all required fees should be mailed to: Cashier Indiana Department of Environmental Management 100 N. Senate Ave - Mail Code 50-10C Indianapolis, IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management. DO NOT SEND CASH.

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