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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