Certified Drinking Water Operators Application * Please place an “X” in the appropriate box indicating which type of license you are applying for: 0 Water Operator License 0 Operator In Training License 0 Reciprocal License 0 Limited License (Daycare/School) * Please print or type: Name: _______________________________ Social Security # ____ - ___ - ______ First MI Last Home Address: _____________________________________________________________ No. and Street ______________________ _________________ _________________ City State Zip Code Home Phone No.________________________ Work Phone No._______________________ Area Code Area Code E-Mail Address: _____________________________________________________________ *NOTE: Under the Federal Privacy Act 5, USC 552a, disclosure of your social security number is voluntary. It will be used for the purpose of a unique internal identifier. Have you previously filed an application for a license with the Division of Public Health? 0 Yes 0 No Have you taken a Division of Public Health examination for water operator licensing? 0 Yes 0 No Score: ______________ Date Taken: ____________ EDUCATION Do you have a high school diploma or equivalency certificate (GED)? 0 Yes 0 No Do you have a college degree? (optional) 0 Yes 0 No Name & Location of college Dates Attended Major Degree From To ______________________________ _____ ________ ______________ ____________________ ______________________________ _____ ________ ______________ ____________________ ______________________________ _____ ________ ______________ ____________________ Drinking Water System Employment Record (Begin with present position and work back through applicable experience) NAME OF PUBLIC WATER SYSTEM AT WHICH YOU ARE OR EXPECT TO BE EMPLOYED: Name of Employer ___________________________________________________________________ Address & Phone Number _____________________________________________________________ Position/Title _____________________________________________________________________ Dates of Employment From: _________________ To: _________________ Treatments _________________________________________________________________________ Have these treatments been in place the entire time you have worked there? 0 Yes 0 No Full Time _____ Part Time _____ If part time, give the number of hours worked per week: ____ Time Employed: Direct Responsible Charge* _____ Yrs. _____ Mos. Operating Experience** _____ Yrs. _____ Mos. This section below is to be completed by the applicant’s current supervisor To the best of my knowledge, I certify that the above information is factual and accurate _________________________ _________________________________ ______________ Printed Name Supervisor’s Signature Date PREVIOUS WATER SYSTEM EMPLOYMENT: Name of Employer ___________________________________________________________________ Address and Phone Number ___________________________________________________________ Position/Title _____________________________________ Dates of Employment From _______ to _______ Treatments _________________________________________________________________________ Have these treatments been in place the entire time you have worked there? 0 Yes 0 No Full Time _____ Part Time _____ If part time, give the number of hours worked per week: ____ Time Employed: Direct Responsible Charge* _____ Yrs. _____ Mos. Operating Experience** _____ Yrs. _____ Mos. *Direct Responsible Charge means a certified water system operator assigned accountability for performance of active, on-site operational duties. **Operator means a licensed person who works in a water treatment facility and/or a water distribution system who may be a direct responsible charge or may work under a direct responsible charge. Base Level License Includes: Disinfection Distribution Hypochlorination Flow < 500 gpm at 20 psi Applicants applying for a Reciprocal License need to fill out the information in the area below. Applicants must provide a copy of their current license/certificate and provide a copy of that State’s licensing requirements. State in which licensed and current classification _______ License # __________ ACKNOWLEDGEMENT (read this section carefully) I, the undersigned, certify that I am the above applicant; that all statements made and information contained in this application are true and correct to the best of my knowledge and belief; that I understand that any omissions of misrepresentations may result in ineligibility for certification or revocation of any certificate granted. I understand that the enclosed fee is non-refundable. Further, should I have received the certification under false circumstances, I will immediately surrender the certificate to the Division of Public Health, Office of Drinking Water. I also consent to a thorough investigation of my application for the purpose of verification of my qualifications for certification. I also understand that by signing below I give the Division of Public Health, Office of Drinking Water the authority to use and report this information and my test results for statistical and demographic purposes only. I waive all claims and agree to indemnify and hold harmless the Division of Public Health, Office of Drinking Water for any action taken pursuant to the rules and standards of the Division of Public Health, Office of Drinking Water with regard to my application and / or my certification except claims based on gross negligence or lack of good faith. __________________________________ ______________ Signature of applicant Date IMPORTANT: Read carefully before submitting your application. - Have you answered all of the questions? Please check to make sure you have completed the application. - Have you signed and dated the application above? - Has your current supervisor signed and dated the appropriate employment block? - Have you provided all necessary documentation? - Incomplete applications will be returned. - Send you application and all necessary documentation to: Division of Public Health Office of Drinking Water Blue Hen Corporate Center Suite 203, 655 Bay Road Dover, DE 19901 DO NOT WRITE IN THE SECTION BELOW DO NOT REMOVE THIS PAGE – FOR ADVISORY COUNCIL USE ONLY Approved? Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Secretary or designee approval: Yes No Date: __________ Comments: Second Submittal Approved? Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Reviewed By: ______________________ _______________ _________ _____ _____ Printed Name Date Reviewed Initials Yes No Doc. No. 35-05-20/07/08/03