Free 45675.pdf - Indiana

FOR OFFICE USE ONLY
Indiana Drinking Water Approval Number

APPLICATION FOR APPROVAL OF TRAINING FOR CONTINUING EDUCATION - DRINKING WATER
State Form 45675 (R2 / 4-07) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH 327 IAC 8-12-7.1(a) (b) Instructions This application must be completed for all drinking water training courses for which continuing education credits will be given. The notice of application approval and the IDEM approval number must be obtained before continuing education contact hours are given. Any change in instructor or course presentation will require reevaluation. Providers of approved training must comply with requirements of 327 IAC 8-12-7.1 (a) and (b). Name of training course Maximum Credit Hours

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

Name of organization offering the course Address (number and street, city, state, and ZIP code) Course instructor(s) [indicate whether certified operator(s)] Instructor Name(s)

Yes

No

Address (number and street, city, state, and ZIP code) Occupation (attach resume or biography) Name of standby instructor Address (number and street, city, state, and ZIP code)

Number of Contact Hours for this course (a contact hour is defined as a sixty minute participation in an approved classroom program or sixty minutes of participation in an approved program not requiring classroom participation): Method of attendance monitoring and verification (be specific or attach samples)

Cost of course Course Content: Attach an outline or narrative, brochure, agenda, workbook, etc. Include samples or description of any visual aids and handouts. Include amount of time spent on each topic. (Application cannot be evaluated without this.) Date(s) course will be presented (month, day, year) Location(s) course will be presented Name of Training Provider Contact Person Address (number and street, city, state, and ZIP code) Telephone Number

Send a copy of the course approval notification letter to the following individual(s)
Name Address (number and street, city, state, and ZIP code) Name Address (number and street, city, state, and ZIP code)