ii iii iv b a adeq wastewater license exam application · page 2 of 3 application fee (select one):...

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For ADEQ OFFICE USE ONLY

Test Location: ADEQ: 8:30am / 1:00pm WWL(s) Renewed? YES / NO

OTHER: If No: date contacted: by:

Test Date: Date app rcvd @ ADEQ: Test Score: PASS / FAIL

Prepaid Fee: $40 exam $20 re-exam Graded by:

Approved by: for Exam: I II III IV B A Date:

ADEQ Wastewater

License Exam Application

This application is submitted pursuant to Arkansas Code Annotated § 8-5-201 et seq., and Arkansas Pollution Control & Ecology Commission Regulation 3.

All Applicants must INITIAL each statement, acknowledging that you have read and fully understand each statement:

I understand that my FULLY COMPLETED APPLICATION must be received and EXAM FEE(s) PAID IN FULL to ADEQ no less

than five (5) business days prior to the desired exam date. (NOTE: Class IV application, additional documents, and fee payment are due

twenty (20) business days prior to exam.)

I understand that submission of an incomplete application, including an application that has not been paid in full by the deadline, will

result in the examinee being barred from testing on the requested date.

Qualified applicants with disabilities, as defined in the Rehabilitation Act of 1973 or the Americans with Disabilities Act of 1990,

may request any needed reasonable accommodations to participate in the licensing process.

Please PRINT CLEARLY (use Black or Blue Ink only – no pencil) Today’s Date:

Exam Date: Location: If testing at ADEQ, what time?

Select one: 8:30am / 1:00pm

Is this a Re-Test? NO YES - Date of previous exam: (must be at least 90 days prior to requested exam date)

Complete Each of the following:

Current Wastewater License # or I do not currently hold a Wastewater License.

Social Security Number (PRINT CLEARLY): - - (Required by Act 1163 and to be reported to AR Office of Child Support Enforcement)

Name (PRINT CLEARLY):

Home Mailing Address:

City: State: Zip Code:

Home Phone # ( ) - Cell/Other Phone # ( ) -

Employer Name:

Work Mailing Address:

City: State: Zip Code:

Work Phone # ( ) - Alternate Phone # ( ) -

Email (recommended): Email addresses are used for ADEQ Wastewater Operator Licensing correspondence only.

Training (select one):

I have Pre-Registered with ARWA or AETA for the following classroom course:

I have taken the appropriate Online Course and have attached a copy of my Certificate of Completion.

Other Training (explain):

How many Total Training Hours are currently documented for you on ADEQ’s website?

What License Level are you testing for? (select one):

Municipal License (select ONE): I II III IV (additional Class IV exam requirements apply – see Page 3 of application)

Industrial License (select ONE): Basic Advanced

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Application Fee (select one):

Exam - $40.00 per Application (initial fee per license level attempted – re-test fee applies for retaking a failed exam)

Re-Test - $20.00 per Application (re-test date must be at least 90 days after failed exam)

Payment Option (select one):

Invoice me for an Online Credit Card Payment of the applicable fee. (ADEQ accepts Visa, MasterCard, Discover, American Express,

and state-issued P/Cards. Minimal service charge applies to all credit card payments.) Applications can be sent to ADEQ’s Licensing Staff Email:

[email protected]. Email my invoice to (required if box is checked):

I have enclosed a Check / Money Order with this application for the appropriate fee selected above. (Make payable to:

ADEQ-WWL and Mail To: ADEQ / Attn: WWL / 5301 Northshore Drive / North Little Rock, Arkansas 72118)

Bill me using PO#: (This option is only available to State or Corporate offices.)

Employment Background: I currently have total years of Water/Wastewater Experience. (If “0” skip to next section)

Only list experience DIRECTLY related to Treatment System Operation, Maintenance, and/or Management. Include job duties for each specific

position held. Attach additional information if required or necessary for clarification. Incomplete or vague job descriptions will not be accepted.

Dates of Employment Current/Most Recent Employer:

From: To: Company:

(Month/Year) (Month/Year) Address:

Supervisor's Name: Contact#:

Below, describe all job duties (not job titles) directly related to wastewater treatment. (Any duties indirectly related to wastewater may be listed for consideration, separately, at the bottom of this page.)

Dates of Employment Previous Employer #1:

From: To: Company:




Dates of Employment Previous Employer #2:

From: To: Company:




Please use the following space to list any INDIRECT (water-related) training you wish to submit for consideration of exam qualification:

mailto:[email protected]

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Work Experience Validation by Employer:

I, the Applicant, am CURRENTLY EMPLOYED.

Unless applicant is currently unemployed, the following section must be completed by applicant’s current Supervisor (or a current Employment

Representative of applicant) for the employment history described above to be considered for experience credit on this application.

I, the undersigned Supervisor / Employment Representative, CERTIFY THAT THE EXAM APPLICANT has provided an accurate and

complete description of his/her wastewater treatment experience, to the best of my knowledge.

Name of Supervisor / Employment Representative (PRINT CLEARLY):

Title: Contact #:

Supervisor / Employment Representative Signature: Date:

I, the Applicant, am CURRENTLY UNEMPLOYED.

Educational Background for Evaluation of Experience:

High School Diploma: YES - Year received: NO - Was a GED earned? YES - Year received: NO

High School Last Attended: City/State:

College or Specialized Education (official transcript must be submitted to receive WWL training credit)

Name of Institution Location Degree Obtained or

Applicable Course Attended

City:

State:

City:

State:

City:

State:

Class IV Exam Application - Additional Requirements:

Attach a résumé of Employment History for the past ten (10) years.

Date Class III license was Issued:

Years of Wastewater Experience:

Years of Supervisory Experience:

I, the undersigned Applicant, certify that the information provided on this application is true and correct to the best of my knowledge. I authorize

the release of my employment, education, and license records to ADEQ, to the extent necessary to determine my eligibility to obtain a license.

I understand my License and Application information, excluding my personal information, is available to the public under the Freedom of

Information Act. I agree to perform my duties as a Licensed Operator or Operator-in-Training in accordance with all applicable state and federal

laws and regulations, and I understand that failure to do so may result in administrative and/or civil penalties and the loss of my wastewater

license. I understand that an Apprentice Certificate is issued for a non-renewable six (6) month term. I understand that a Wastewater License issued

to me will be valid for the remainder of the current renewal period. I understand that renewal of a Wastewater License requires a minimum

of twenty-four (24) hours of approved training for each two-year renewal period (July 1 - June 30 of odd years). I understand that all

training must be submitted to ADEQ on ADEQ’s WWL Training Hours Submittal Form. Training hours may be submitted to ADEQ at any

time during the two-year license period, but must be submitted no later than the end of each renewal period, June 30 of odd numbered years.

I understand that a renewal fee of forty dollars ($40.00) must also be submitted no later than the end of each renewal period for each license that

is renewed.

Applicant Signature (required): Date:

NOTE: submittal of the ADEQ Wastewater Licensing Exam Application IS NOT registration for the training course.

Contact the appropriate training facility - AETA (870-574-4550 / 870-574-4589) or ARWA (501-676-2255) - for all information

on course registration and separate fees that may be associated with training, either in a classroom setting or online.

Updated April 2018

ii iii iv b a adeq wastewater license exam application · page 2 of 3 application fee (select one):...

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