Requested for Approved CE Training Form 05/2020
MARYLAND DEPARTMENT OF THE ENVIRONMENT1800 Washington Boulevard, Baltimore, MD 21230 (410) 537-4162 STATE BOARD OF WELL DRILLERS (410) 537-3168 (FAX) Request for Approval Continuing Education/Training Fill out each numbered section completely.1. PROGRAM TITLE _____________________________________________________________________ 2. SPONSOR’S NAME _________________________________________ PHONE #__________________ MAILING ADDRESS ___________________________________________________________________ CITY ____________________________ STATE __________________ ZIP CODE _____________ 3. PROGRAM LOCATION ________________________________________________________________ 4. PROGRAM DATE(S) AND TIME(S) ______________________________________________________5. CONTACT PERSON/SUBMITTED BY____________________________________________________ 6.EMAIL ADDRESS ____________________________________________________________________ 7.PHONE # _______________________________ DATE SUBMITTED _____________________ Attach program agenda, syllabus or outline showing the exact instruction times for each subject.Submit above document and copy of attendance certification to:Maryland Board of Well Drillers1800 Washington BlvdBaltimore, MD 21230DO NOT WRITE BELOW THIS LINE ****************************************************************************************** ACTION TAKEN BY BOARD AFTER TRAINING WAS REVIEWED ON _______________________ : _____ APPROVED FOR _______ CLOCK HOURS_____ DISAPPROVED REASON_____________________________________________________________ ___ TABLED REASON_____________________________________________________________ MDE/WMA/BWD/TRN 1 of 1Revision Date (05/20) TTY Users 1-800-735-2258 ................
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