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FOR IDEM USE ONLY Approval Number: Technical Contact Hours:

APPLICATION FOR APPROVAL OF TRAINING FOR WASTEWATER OPERATOR/APPRENTICE CONTINUING EDUCATION CREDIT
State Form 51138 (R2 / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

General Contact Hours:

INSTRUCTIONS In accordance with 327 IAC 5-22-16, this application must be properly completed for all training courses for which wastewater continuing education credit hours are requested. Forms should be submitted for advance approval at least 60 days before the first date the course is conducted, but must be submitted no later than 90 days after training completion in order to be considered for approval. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Department of Environmental Management 100 N. Senate Ave. - Mail Code 65-42 Indianapolis, IN 46204-2251 Notice of application approval and IDEM approval number must be obtained before continuing education contact hours are allowed. Any change in instructor, course presentation, course date(s) or location(s) will require re-evaluation. Providers of approved training must comply with the requirements of 327 IAC 5-22-17.
1. NAME OF TRAINING COURSE:

2. NAME OF TRAINING COURSE PROVIDER: 4. NAME OF TRAINING PROVIDER CONTACT PERSON:

3. EMAIL 5. TELEPHONE NUMBER:

6. TRAINING PROVIDER ADDRESS (number and street, city, state, zip code): 7. NAME OF ORGANIZATION SPONSORING COURSE (If different than provider in #2 above):

8. SPONSOR ADDRESS (number and street, city, state, zip code): 9. COURSE INSTRUCTOR(S): Name: Indiana Certified Operator? YES Certification #:________________ NO Occupation (attach resume or bio):

Name: Indiana Certified Operator? YES Certification #:________________ NO Occupation (attach resume or bio):

10. METHOD OF ATTENDANCE MONITORING AND VERIFICATION (be specific or attach samples): 11. COURSE CONTENT - Application cannot be evaluated without the following information: Attach either an outline or narrative, brochure, agenda, workbook, etc. that includes specific topics that are included in the course presentations. Include amount of time spent on each topic. Indicate and provide explanation whether the topic deals with technical matters related directly to wastewater treatment plant and sewer system operations, maintenance, management or supervision or general matters that enhance the performance of the certified operator's responsibilities but are not directly related to wastewater treatment plant and sewer system operations, maintenance, management or supervision. 12. TECHNICAL CONTACT 13. GENERAL CONTACT 14. TOTAL # OF CONTACT HOURS FOR COURSE HOURS: HOURS: (Technical plus General Hours):

* A contact hour is defined as a 50-60 minute instruction session approved by the commissioner and involving a qualified instructor or lecturer.

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15. LIST ALL DATE(S) AND CORRESPONDING LOCATION(S) WHERE COURSE APPROVAL IS REQUESTED:

16. Signature of Applicant: I, the undersigned, certify under penalty of law that this document and all attachments were prepared under my direction or supervision and that all statements made and information provided is true and correct to the best of my knowledge and belief. I also understand that any omissions or misrepresentations may result in denial of this course for continuing education credit. Signature____________________________________________ Printed Name_________________________________________

I am:

Training Provider

Course Sponsor

Certified Operator

Apprentice

Other_____________

17. SEND A COPY OF THE COURSE APPROVAL LETTER TO THE FOLLOWING INDIVIDUAL(S). Name: Name:

Address (number and steet, city, state, ZIP code ):

Address (number and steet, city, state, ZIP code ):

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