<p> Florida Water & Pollution Control Operators Association A Non-Profit Association Serving Water & Wastewater Professionals in the State of Florida</p><p>SYSTEMS OPERATORS APPLICATION FORM WATER DISTRIBUTION Class “3” Location of School: Suncoast Public Works Academy - Sarasota Date/s of School: Sept.10-14 2012 ______</p><p>NAME: Last 4 digits of SS#: </p><p>MAILING ADDRESS: (House Number) (Street/Ave) (Apt.)</p><p>(City) (County) (State) (Zip)</p><p>Email Address: ______</p><p>Work Phone: ( ) Fax: ( ) </p><p>Employer: Job Title: </p><p>PLACE AND “X” NEXT TO THE APPROPRIATE LEVEL OF TRAINING AND/OR EXAM:</p><p>Water Distribution Level 3: _____ course & exam _____ course only _____ exam only* _____ CEU (DW/DS28096, 3.0 CEU’s) Water Distribution Level 2: _____ course & exam _____ course only _____ exam only* _____ CEU (DW/DS28097, 3.0 CEU’s) Water Distribution Level 1: _____ course & exam _____ course only _____ exam only* _____ CEU (DW/DS2304, 3.0 CEU’s)</p><p>* YOU MUST ATTACH A COPY OF YOUR ATTENDANCE CERTIFICATE FOR THE APPROPRIATE LEVEL TECHNOLOGY TRAINING COURSE.</p><p>STUDENTS ARE RESPONSIBLE FOR PURCHASING THEIR OWN TEXTBOOK! All students will use “Water Distribution System Operation and Maintenance.” Level 1 will also use “Manage for Success: Effective Utility Leadership Practices.” Textbooks may be purchased from Dr. Kenneth Kerri: </p><p>Office of Water Programs, CSU - Sacramento Phone: 1-916-278-6142 6000 J Street Fax: 1-916-278-5959 Sacramento, CA 95819</p><p>To receive a “Certificate-of-Completion”: LEVEL 3: (A) Must be at least 18 years of age. (B) Must furnish evidence of having completed the FW&PCOA Level 3 Technology Training course. (C) Must pass the Level 3 written exam with a score of 70% or higher. LEVEL 2: (A) Must furnish evidence of having completed the FW&PCOA Level 2 Technology training course. (B) Must pass the Level 2 written exam with a score of 70% or higher. LEVEL 1: (A) Must furnish evidence of having completed the FW&PCOA Level 1 Technology training course. (B) Must pass the Level 1 written exam with a score of 70% or higher.</p><p>Please note that while the FW&PCOA does not require evidence of a high school diploma or equivalent for its water distribution operator training programs, applicants for Florida Department of Environmental Protection (FDEP) licensure must provide proof that they hold a valid high school diploma or equivalent issued by an FDEP approved institution. Contact the FDEP Operator Certification Program office (850-245-7500) for details.</p><p>Request for an Oral Exam: Medical documentation that is in agreement with the Americans with Disabilities Act (ADA) must be attached. Please place an “X” below to indicate your request for an oral exam.</p><p>_____YES: I request to take an oral exam, documentation attached.</p><p>Applicant’s Signature: Date: </p><p>FEES: FW&PCOA Members: $300.00 for course and exam or for course only (Indicate Region #______). FW&PCOA Non-members: $330.00 for course and exam or for course only. Members and Non-members: $90.00 for exam only.</p><p>MAIL: Fees, payable to Region XII FW&PCOA, with original application (all documentation attached) to: Region XII FW&PCOA, c/o Karen Johnson, </p><p>Revised 11/11 Florida Water & Pollution Control Operators Association A Non-Profit Association Serving Water & Wastewater Professionals in the State of Florida</p><p>3305 Gulf Watch Court, Sarasota, FL 34231. Phone (941) 922-4647, [email protected], www.FWPCOA.org.</p><p>Revised 11/11</p>