Certification Renewal Form

USET CERTIFICATION BOARD FOR WATER & WASTEWATER TREATMENT PLANT OPERATORS AND LABORATORY ANALYSTS

RENEWAL Application for USET Certfication
Last Name	First Name	MI
Work Title
Street Address
City	State	Zip Code
E-mail
Business Phone	Home Phone
Tribe Currently Employed By

Certificate Renew Requested: (Mark completely and submit total fee due - See Fee Schedule)
Water	Wastewater
Class I-Water Treatment System Operator Class II-Water Treatment System Operator Class III-Water Treatment System Operator Class IV-Public Water Supply System Operator Water Distribution System Operator Water Laboratory Analysis	Class I-Wastewater Treatment System Operator Class II-Wastewater Treatment System Operator Class III-Wastewater Treatment System Operator Class IV-Bio Wastewater Treatment System Operator Wastewater Distribution System Operator Wastewater Laboratory Analysis Industrial Wastewater
Has there been any changes made to the water system/facility or to your certification status since your last certification approval? Yes No
If yes, please describe and submit a copy of your certification reflecting this change: