Application Date
WPCSOCC (WATER POLLUTION CONTROL SYSTEM OPERATORS CERTIFICATION COMMISSION)
CONVERSION APPLICATION Requires $20.00 Non-refundable fee Please complete all sections of this application legibly in BLACK INK.
PERSONAL INFORMATION Last 4 of SSN:
Cert #:
Convert to:
Applicant’s Name: Mr / Mrs / Ms (As you wish it to appear on your certificate)
(First)
(Middle)
(Last)
(Jr., Sr., III etc.)
Address: (Mailing address or PO Box)
(City)
(State)
Work Telephone:
/
(Zip Code)
(County)
Home Telephone:
/
Email:
OPERATIONAL EXPERIENCE List all work experience demonstrating hands-on experience in the operation of the type and grade system for which you are seeking certification. Include position title and specific details in describing actual duties performed. Attach additional sheets, if necessary. Dates of Employment - From:
To:
Position Title:
Hours/week:
Facility Name:
Permit #:
Specific Duties Performed:
APPLICANT’S SIGNATURE I hereby certify that the information given in this application is correct to the best of my knowledge. I understand that providing false information on this application may lead to the revocation of any and all certificates issued to me by the WPCSOCC. I have read the eligibility requirements for the type/grade certification that I am seeking and believe that I am eligible for that certification.
Signature of Applicant
Date
Make certain to have a supervisor (or other official) verify your experience and sign the form on the 2 nd page under the section RECOMMENDATION BY APPLICANT’S SUPERVISOR! Failure to obtain verification of experience may result in denial of this request. FOR WPCSOCC STAFF USE ONLY
Received Date
Payee’s Name__________________________________________________ Check # ___________________ Check Date_____________Amount $__________ Renewals current? Yes Comments
No
Approved by
Denied by
Date
WPCSOCC CONVERSION APPLICATION
RECOMMENDATION BY APPLICANT’S SUPERVISOR I have reviewed this application and hereby verify that all of the information and statements provided by the applicant are true and correct to the best of my knowledge. I understand that I am responsible for verifying the experience information provided on this application and that any false information provided by the applicant may lead to the revocation of any and all certificates issued to me by the Water Pollution Control System Operators Certification Commission (WPCSOCC). Signature of Supervisor
Date
Supervisor’s name (please print) Supervisor’s title (please print) Supervisor’s telephone
Extension
Make $20.00 CONVERSION FEE checks payable to: WPCSOCC Mail completed application with payment to:
WPCSOCC 1618 Mail Service Center Raleigh NC 27699-1618
Page 2 Revised 12/2012 WPCSOCC Conversion App
CONVERSION APPLICATION Requires $20.00 Non-refundable fee Please complete all sections of this application legibly in BLACK INK.
PERSONAL INFORMATION Last 4 of SSN:
Cert #:
Convert to:
Applicant’s Name: Mr / Mrs / Ms (As you wish it to appear on your certificate)
(First)
(Middle)
(Last)
(Jr., Sr., III etc.)
Address: (Mailing address or PO Box)
(City)
(State)
Work Telephone:
/
(Zip Code)
(County)
Home Telephone:
/
Email:
OPERATIONAL EXPERIENCE List all work experience demonstrating hands-on experience in the operation of the type and grade system for which you are seeking certification. Include position title and specific details in describing actual duties performed. Attach additional sheets, if necessary. Dates of Employment - From:
To:
Position Title:
Hours/week:
Facility Name:
Permit #:
Specific Duties Performed:
APPLICANT’S SIGNATURE I hereby certify that the information given in this application is correct to the best of my knowledge. I understand that providing false information on this application may lead to the revocation of any and all certificates issued to me by the WPCSOCC. I have read the eligibility requirements for the type/grade certification that I am seeking and believe that I am eligible for that certification.
Signature of Applicant
Date
Make certain to have a supervisor (or other official) verify your experience and sign the form on the 2 nd page under the section RECOMMENDATION BY APPLICANT’S SUPERVISOR! Failure to obtain verification of experience may result in denial of this request. FOR WPCSOCC STAFF USE ONLY
Received Date
Payee’s Name__________________________________________________ Check # ___________________ Check Date_____________Amount $__________ Renewals current? Yes Comments
No
Approved by
Denied by
Date
WPCSOCC CONVERSION APPLICATION
RECOMMENDATION BY APPLICANT’S SUPERVISOR I have reviewed this application and hereby verify that all of the information and statements provided by the applicant are true and correct to the best of my knowledge. I understand that I am responsible for verifying the experience information provided on this application and that any false information provided by the applicant may lead to the revocation of any and all certificates issued to me by the Water Pollution Control System Operators Certification Commission (WPCSOCC). Signature of Supervisor
Date
Supervisor’s name (please print) Supervisor’s title (please print) Supervisor’s telephone
Extension
Make $20.00 CONVERSION FEE checks payable to: WPCSOCC Mail completed application with payment to:
WPCSOCC 1618 Mail Service Center Raleigh NC 27699-1618
Page 2 Revised 12/2012 WPCSOCC Conversion App
