Requested for Approval for CE Training: 5/2020
MARYLAND DEPARTMENT OF THE ENVIRONMENT
1800 Washington Boulevard, Baltimore, MD 21230
(410) 537-4162 STATE BOARD OF WELL DRILLERS (410) 537-3168 (FAX)
Request for Approval Continuing Education/Training
A. 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 _____________________
B. Attach program agenda, syllabus or outline showing the exact instruction times for each subject.
C. Submit above document and copy of attendance certification to:
Maryland Board of Well Drillers
1800 Washington Blvd
Baltimore, MD 21230
DO 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 1
Revision Date (05/20)
TTY Users 1-800-735-2258
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