CEU Request Form - Wa



102870-238125Request for Wastewater TrainingContinuing Education UnitsRequest Date FORMTEXT ?????Course Title FORMTEXT ????? Course Location FORMTEXT ?????Start Date FORMTEXT ????? End Date FORMTEXT ????? Total Classroom Hours FORMTEXT ?????CEUs Requested (1 hour class time = 0.1 CEU) FORMTEXT ????? Course format: Classroom FORMCHECKBOX Correspondence FORMCHECKBOX On-line FORMCHECKBOX Conference FORMCHECKBOX Recurring FORMCHECKBOX Explain how this course meets the professional growth criteria to operate and maintain a domestic wastewater treatment plant or to manage the operation and maintenance of a domestic wastewater treatment plant. FORMTEXT ?????How will attendance be monitored/verified? FORMTEXT ?????Contact Name FORMTEXT ????? Company FORMTEXT ?????Mailing address FORMTEXT ????? City FORMTEXT ????? State FORMTEXT ????? Zip FORMTEXT ?????Phone Number FORMTEXT ????? e-mail FORMTEXT ?????Required Attachments: FORMCHECKBOX Course Agenda with timeline – include start and end times, breaks & lunch FORMCHECKBOX Course Summary or Brochure w/course summaries FORMCHECKBOX Instructor Information – short biography and credentials or Brochure w/instructor biosReturn completed form and required attachments to:Department of EcologyWastewater Operator CertificationPO Box 47696Olympia, WA 98504-7696Or email completed form and attachments to: mailto:opcert@ecy.Accommodation Requests:To request ADA accommodation including materials in a format for the visually impaired, call Ecology at 360-407-6600. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341.OpCert Staff Use CEUs Course ID Approval Date Expiration Date Reviewed by ................
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