N.H. Code Admin. R. Env-Dw 502.05

Current through Register No. 25, June 20, 2024

Section Env-Dw 502.05 - Required Application Information

An applicant shall provide the following information on or with the application form identified in Env-Dw 502.04(b)(1):

(a) The name, mailing address, date of birth, telephone number including area code, and e-mail address of the applicant;

(b) If the applicant is currently employed by a water system or other water company, the employer's name, mailing address, telephone number including area code, e-mail address, and PWS identifier, if applicable;

(c) The type and grade of certification being applied for, as follows:

(1) Whether the application is for a new certification, an upgrade to an existing certification, the reactivation of an inactive certification, a re-test, or reciprocity and, if the application is based on reciprocity, the state and certification number; and

(2) Whether the application is for a grade IA combined distribution and treatment certification or a grade I, grade II, grade III, or grade IV treatment certification, distribution certification, or both certifications;

(d) Information about all other professional or occupational certifications, licenses, permits, or other required authorizations and for each, the unique identification number, state of issuance, and current status, and whether the applicant has ever been refused a professional or occupational license or had one suspended or revoked, and if so an explanation;

(e) Information about the applicant's education, including:

(1) The name and location of the high school the applicant attended, the number of years attended, and the year the applicant graduated or otherwise obtained a high school equivalency (HSE) certificate;

(2) The name and location of each college the applicant attended, the number of years attended, the year a degree was awarded, and the type of degree awarded and the major; and

(3) Copies of all college transcripts;

(f) Information about the applicant's training, including the following for each course, seminar, or other program:

(1) The title of the program;

(2) The name of the program's provider;

(3) A brief description of the material covered in the program;

(4) The amount of active instruction time;

(5) The date the applicant completed the course; and

(6) A copy of the certificate of completion, transcript, or other documentation that the applicant completed the program;

(g) Information about the applicant's work experience, including the following for each position beginning with the current or most recent:

(1) Employer name, location address, telephone number including area code, and email address;

(2) The name and title of the applicant's supervisor;

(3) The dates of employment and the number of hours worked per week; and

(4) The applicant's job title and an explanation of the applicant's duties;

(h) For applicants other than for grade I-A, verification of work experience in the form of a statement signed by a responsible official of the applicant's employer that:

(1) The information provided by the applicant on the application form is true and complete to the best of the official's knowledge and belief; or

(2) If the information is not true and complete or if the applicant is no longer employed by that employer, a separate statement, signed as specified in Env-Dw 502.06(c), that provides the applicant's dates of employment, the number of hours worked per week, the applicant's job title, and an explanation of the applicant's duties;

(i) Whether the applicant is seeking to substitute for education or experience as allowed by Env-Dw 502.22, and if so, an explanation of the substitution; and

(j) Any additional information or comments that are relevant to the application that the applicant wishes to provide.

N.H. Code Admin. R. Env-Dw 502.05

(See Revision Note at part heading for Env-Dw 502) #9410, eff 3-12-09 (formerly Env-Ws 367.05 )

Amended by Volume XXXVII Number 37, Filed September 14, 2017, Proposed by #12363, Effective 8/19/2017, Expires 8/19/2027.