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FOR BOARD USE ONLY Date of Review Approved Disapproved v Address FOR BOARD USE ONLY Fee Paid Date Receipt # Applicant # Georgia State Board of Examiners for Certification of Water and Wastewater Treatment Plant Operators and Laboratory Analysts PO Box 13446 Macon, GA 31208 Phone (478) 207-1460 Fax (478) 207-1468 www.sos.state.ga.us/plb/water APPLICATION FOR REINSTATEMENT OF CERTIFICATION Reinstatement Fee: $165.00 Non-Refundable (Make payable to the GA Water/Wastewater Board) • • • • • Please type or print clearly Enclose fee Use a separate Application for each lapsed certificate The Application must be received in the Board office at least 3 weeks prior of Board Meeting An incomplete Application will not be processed and will be sent back to the applicant Name : Social Security #: Mailing Address: Number and Street City State Zip Code Number and Street City State Zip Code Home Address: Daytime Telephone #: Home Telephone #: Email Address: Employer Name and Address: Supervisor: Employed Dates: From To STATEMENT OF APPLICANT: I hereby apply to reinstate my lapsed Georgia Certificate for Class/Category License Number Date Expired Reason for failing to renew: Enclosed are Excerpts of Board Rules 750-6, Renewal and Continuing Education and 750-7-.02 Reinstatement Revised 04/2003 Please Check: _____ I hereby make this Application in accordance with Rule 750-7-.02 because my certificate has been lapsed for 2 years or less. I have enclosed the following: 1. Application 2. Reinstatement Fee $165.00 3. Documentation of Continuing Education 4. Evidence of education required for this class and category of certificate. (Submit only if current education requirements in Rule 750-7-.02 differ from those required at time of original Certification in this class and category) OR _____ 1. 2. 3. 4. I hereby make this Application in accordance with Rule 750-7-.03 because my certificate has been lapsed for more than two (2) years. I have enclosed the following: Application Reinstatement Fee $165.00 Proof of passage of the examination since my certificate lapsed Applications for examination are available at the Board’s website: www.sos.state.ga.us/plb/water or by calling AMP at (800) 345-6559. Evidence of education required for this class and category of certificate. (Submit only if current education requirements in Rule 750-7-.03 differ from those required at time of original Certification in this class and category) The following questions must be answered regarding the period since the date of your last renewal: 1. Have you been convicted of a felony or misdemeanor (other than minor traffic violation) or entered a plea of guilty, nolo contendere, or plea under the “First Offender Act”? DUI and DWI are not minor No If yes, attach a certified copy of conviction traffic offenses. Yes 2. Have you had a license or certificate revoked, suspended, or otherwise sanctioned by any Board or No If yes, attach a certified copy of order agency in Georgia or any other state? Yes 3. Were you denied issuance of or, pursuant to disciplinary proceeding, refused renewal of any license or certificate by any Board or agency in Georgia or any other state? No If yes, attach a certified copy of order and a brief statement explaining why Yes AFFIDAVIT: I hereby swear under penalty of perjury that the information contained on this application is true and correct to the best of my knowledge and belief. If requested, I understand that I and/or my employer may be required to promptly provide additional information for this Application to be processed. Date: Signature of Applicant: Sworn to and subscribed before me this Signature of Notary Public My Commission Expires Revised 04/2003 day of , . NOTARY SEAL CHAPTER 750-6 RENEWAL AND CONTINUING EDUCATION Excerpt 750-6-.01 Expiration Date. All certificates expire June 30 of odd-number years. 750-6-.02 Renewal of a Certificate. Amended. (1) An Application for renewal of a certificate must be accompanied by a renewal fee (See Fee Schedule) and attestation of continuing education points accumulated since the last renewal period. The following chart lists the required number of points for each renewal certification: CERTIFICATION HELD CONTINUING EDUCATION POINTS Class I Operator Water & Wastewater 18 Class II Operator Water & Wastewater Industrial Wastewater Operator Laboratory Analyst Water & Wastewater 12 12 12 Class III Operator Water & Wastewater Water Distribution System Operator Wastewater Collection System Operator 6 6 6 Class IV Operator Water & Wastewater 2 (2) The biennial renewal fee is due and payable by June 30 of odd numbered years. A surcharge will be added for payments, which are received within a three-month penalty period, between July 1 and September 30 of odd-numbered years. (See Fee Schedule) Any continuing education points acquired to renew that certificate during the penalty period may not be used again during the next renewal cycle. (3) An individual who passes an examination required by the Board for certification is exempt from all continuing education requirements for the first following renewal period after passage of the exam. 750-6-.03 Renewal of More Than One Certificate. Amended (1) An operator may maintain current certification in only one class of a category. When a person receives a higher-class certificate, their lower class certificate shall be rendered void. (2) An operator or analyst who holds more than one certificate must submit the following: (a) a renewal application for each certificate; (b) a renewal fee for each certificate; and (c) attestation of the highest number of continuing education points which are required to renew any of the Operator’s or Laboratory Analyst’s certificates (i.e., 18, 12, or 6). Revised 04/2003 750-6-.04 (1) Basic, Advanced, and Continuing Education Courses. The Board shall maintain a list of currently approved course providers in accordance with eligibility criteria published by the Board. Course providers must be approved by the Board or its designee in order for applicants to receive credit. The Board may also elect to approve individual courses. A request by a course provider for approval must be submitted on a form that may be obtained from the Board and must be accompanied by the appropriate fee and supporting documents as required by the Board (See Fee Schedule). All course approvals shall expire on or before June 30 of odd-numbered years. (2) Persons who have attended courses which have not received Board approval may petition the Board for approval and the Board may grant credit at its discretion. 750-6-.05 Documentation of Continuing Education. Amended (1) Each operator or laboratory analyst shall maintain for three years their own record of the continuing education activities which they have completed. The Board will not maintain continuing education files. (2) Applications shall attest on their biennial application that they have satisfied the continuing education requirements set out in these Rules Documentation of these activities should be retained be the applicant and sent to the Board (unless required to do so under section 750-6-.05(3) below). False attestation of satisfaction of the continuing education requirements on an application shall subject the applicant to disciplinary action, including revocation. (3) The Board may conduct an audit of the renewal applications to insure compliance with requirements. Applicants who are audited will be required to document their continuing education activities. Documentation must be in the form of a certification of attendance, a statement signed by the provider verifying participation in the activity or an official transcript. Failure to provide the Board with documentation of the hours attested to on the renewal application shall be grounds for disapproving the application for renewal or, if the certificate has been renewed, revoking the certificate. Revised 04/2003 CHAPTER 750-7 REVOCATION AND REINSTATEMENT FOR FAILURE TO RENEW Excerpt 750-7-.01 Revocation for Failure to Renew Failure to renew a certificate by October 1 of renewal year shall have the same effect as revocation of the certificate. 750-7-.02 Reinstatement. (1) Certificates that have not been renewed may be reinstated at the discretion of the Board. An operator or analyst may not be issued more than one certificate number in a class and category. (2) Applications for reinstatement shall be accompanied by: (a) A reinstatement fee established by the Board (see fee schedule); (b) Evidence of the completion, since the last renewal, of the total continuing education points which would have been required if the certificate had been maintained in a current status; and (c) Evidence of meeting the minimum current education requirements for that class and category of certificate. (3) If a certificate has lapsed for a period of more than 2 years, the Board shall require, as a prerequisite for reinstatement, passage of an examination for that category of certificate in lieu of the continuing education in paragraph (2) (b) of this rule. Revised 04/2003