Free 45674.pdf - Indiana

PUBLIC WATER SUPPLY DRINKING WATER OPERATOR CONTINUING EDUCATION CREDIT REPORT
State Form 45674 (R3 / 4-07) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH *The information in this document is confidential according to 327 IAC 8-12-7.6

To ensure proper credit, the Indiana Drinking Water approval number MUST be submitted on this form. Indiana Drinking Water Approval Number

"PWS_______________"
Maximum Credit Hours

Mail to:

Indiana Department of Environmental Management OWQ Drinking Water Branch - Mail Code 66-34 100 N. Senate Avenue Indianapolis, IN 46204-2251

INSTRUCTIONS: To ensure proper credit, print legibly
This form must be completed in order for the attendee to get credit. Be sure to record the certification number and class/grade for each certification for which you are requesting credit. Mail the original form to IDEM at the above address. The Training Provider must retain a copy of the completed form for their records in accordance with 327 IAC 8-12-7.6. Since this is a form of attendance verification, it is requested that this form be distributed during the latter portion of the training session. No credit will be considered when original signatures are not shown. Name of certified operator City: Mailing address (number and street): State: ZIP code: Work telephone number: ( ) Home telephone number: ( )

Check here if this is a change of address.
Title of training course: Name of organization offering the course: Number of contact hours approved for the course:

CREDIT APPLIED TO DRINKING WATER:
Operator certification number: Operator certification number: Operator certification number: Operator certification number: Operator certification number: Operator certification number: Operator certification number: Operator certification number: Date Attended: (Required) Number of contact hours attended and verified: (Required) Signature of instructor or training provider: (Required) Class/Grade: Class/Grade: Class/Grade: Class/Grade: Class/Grade: Class/Grade: Class/Grade: Class/Grade: Location attended: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date: Expiration Date:

Signature of drinking water operator: (Required)