DDW Home

Utah Water Operator Certification Program

CONTINUING EDUCATION UNIT (CEU)

COURSE ACCREDITATION

Instructions: All training must be approved by the Executive Secretary of the Operator Certification Commission. Please fill out this form completely, attach attendance roster and course agenda, and return all forms to the address listed below. If you need assistance, please call the Division of Drinking Water at 536-4200.

Sponsoring Agency:

 
 
 

Location of Training:
 
 
 

Description of Activity:
 
 
 

Name of Instructor(s):

Name:

Address:

Phone:

Name:

Address:

Phone:

Topic(s) of Instruction:

 
 

Date(s) of Instruction:
           

Actual Instruction Time (in hours):

           

Contact Person: Phone Number:
   

 

 

Send completed form to:

Department of Environmental Quality

Division of Drinking Water

Operator Certification Program

150 North 1950 West

P.O. Box 144830

Salt Lake City, Utah 84114-4830

 

You may also fax this form to (801) 536-4211

 

TRAINING ACTIVITY

ATTENDANCE ROSTER

COURSE NAME (SUBJECT)

 

 

COURSE ADDRESS:
 

 

 

DATE: DURATION (HOURS): SPONSOR:
     

 

IMPORTANT: PLEASE PRINT LEGIBLY TO INSURE THAT PROPER CEU’S ARE CREDITED TO YOUR RECORD.

 
FULL NAME  LAST 4 DIGITS of SOC SEC # EMPLOYER CERTIFICATION #
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       

 

ATTENDANCE VERIFIED BY:

                                         AUTHORIZED SIGNATURE:   _______________________________________________________________

                                         PLEASE PRINT NAME:    ______________________________________________________________________

 

 

PLEASE RETURN THIS FORM TO:

UTAH DIVISION OF DRINIKING WATER                                                  You may fax this form to (801) 536-4211

ATTENTION: KIM DYCHES

150 NORTH 1950 WEST

P.O. BOX 144830

SALT LAKE CITY, UTAH 84114-4830