Mail to: - Kentucky
| |Commonwealth of Kentucky |For Official Use Only |
| |Department for Environmental Protection |Do not write in this space |
|Mail to: | | |
| |Application for Approval of Courses for Continuing Education Credit | |
|Division of Compliance Assistance | | |
|Certification and Licensing Branch |Drinking Water Treatment, Distribution, Bottled Water, | |
|Operator Certification Program |Wastewater Treatment and Collection System | |
|300 Sower Blvd. | | |
|Frankfort, KY 40601 |Telephone: 502-782-6189 | |
| |eec.Environmental-Protection/Compliance-Assistance/operator-certifi| |
| |cation-program |Amount Paid: ________________ |
| | | |
| | |Check Number: ______________ |
|COURSE SPONSOR INFORMATION |
|Sponsoring Organization |Agency Interest Number |
| | |
|Key Contact Person Name |Title |
| | |
|Address |City |State |Zip Code |
| | | | |
|E-Mail Address |Web Page |Business Phone Number |
| | | |
If individual requesting approval is different than the key contact person for the sponsor, please complete the following information:
|Contact Person Name |Title |Agency Interest Number |
| | | |
|Address |City |State |Zip Code |
| | | | |
|E-Mail Address |Phone Number |
| | |
|GENERAL COURSE INFORMATION | For official use only. Do not write in this |
| |space. |
| | |
| |Approval Number: |
|Title | |
| | |
|Location |Date(s) |
| | |
|Requested Continuing Education Credit hours for Drinking Water Treatment, Distribution and/or Bottled Water: |
|Requested Continuing Education Credit hours for Wastewater Treatment and/or Collection: |
| Core Content Category: |
|(Can be found on the core content list. Ex.: B3 (Chorine Safety)) |
| One-Time Approval Requested | Two-Year Approval Requested |
|(This course can only be given once) |(This course can be given numerous times within a two year period.) |
|REQUIRED ITEMS |
|(must be attached to submittal, check off as completed) |
| Course Learning Objectives | | |
| Criteria for Successful Completion by Operators | | |
| Timed Agenda (with instructors identified and brief description of topics) | | |
| Credentials for All Instructors | | |
| |
|INFORMATION VERTIFICATION |
|(signature of sponsor’s contact person or individual requesting course approval) |
|I confirm that all information provided with this application is accurate to the best of my knowledge. I understand if providing online courses I may be |
|required to provide the Cabinet with login credentials for review purposes. A complete list of attendees and credits to be awarded to them will be forwarded on|
|a “Continuing Education Activity Report” to the Kentucky Division of Compliance Assistance (within 30 days of completing the course when possible). |
|Printed Name |Title | |
| | | |
|Signature |Date | |
| | | |
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