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Get DOH-352 2012

YOU MUST COMPLETE THIS SECTION IN ITS ENTIRETY FOR THIS APPLICATION TO BE PROCESSED Course Subject DOH-352 11/12 Page 1 of 2 Dates Contact Hours Location Sponsor Signature. NEW YORK STATE DEPARTMENT OF HEALTH Center for Environmental Health Bureau of Water Supply Protection Empire State Plaza Corning Tower Room 1110 Albany New York 12237 Application for Renewal of Certification Water Treatment Plant or Distribution System Operator Instructions To avoid your application being rejected please read and follow these instructions carefully. 1. Complete ALL items in SECTION I and II ONLY. PRINT IN PEN OR TYPE ALL INFORMATION* 2. Include copies of all course completion certificates. 3. BE SURE TO SIGN AND DATE YOUR APPLICATION* FAILURE TO COMPLETE THIS APPLICATION FULLY WILL CAUSE IT TO BE REJECTED AND RETURNED AS INCOMPLETE* I. Applicant Information Phone No* Work Home Email Address Employer Name Employer Address PLEASE ENTER ANY ADDRESS CORRECTIONS IN THE SPACE BELOW County of Employment II. Renewal Training Credits Summarize below all training received towards renewal in the past three years. NEW YORK STATE DEPARTMENT OF HEALTH Center for Environmental Health Bureau of Water Supply Protection Empire State Plaza Corning Tower Room 1110 Albany New York 12237 Application for Renewal of Certification Water Treatment Plant or Distribution System Operator Instructions To avoid your application being rejected please read and follow these instructions carefully. 1. Complete ALL items in SECTION I and II ONLY. PRINT IN PEN OR TYPE ALL INFORMATION* 2. Include copies of all course completion certificates. 1. Complete ALL items in SECTION I and II ONLY. PRINT IN PEN OR TYPE ALL INFORMATION* 2. Include copies of all course completion certificates. 3. BE SURE TO SIGN AND DATE YOUR APPLICATION* FAILURE TO COMPLETE THIS APPLICATION FULLY WILL CAUSE IT TO BE REJECTED AND RETURNED AS INCOMPLETE* I. 3. BE SURE TO SIGN AND DATE YOUR APPLICATION* FAILURE TO COMPLETE THIS APPLICATION FULLY WILL CAUSE IT TO BE REJECTED AND RETURNED AS INCOMPLETE* I. Applicant Information Phone No* Work Home Email Address Employer Name Employer Address PLEASE ENTER ANY ADDRESS CORRECTIONS IN THE SPACE BELOW County of Employment II. Applicant Information Phone No* Work Home Email Address Employer Name Employer Address PLEASE ENTER ANY ADDRESS CORRECTIONS IN THE SPACE BELOW County of Employment II. Renewal Training Credits Summarize below all training received towards renewal in the past three years. NEW YORK STATE DEPARTMENT OF HEALTH Center for Environmental Health Bureau of Water Supply Protection Empire State Plaza Corning Tower Room 1110 Albany New York 12237 Application for Renewal of Certification Water Treatment Plant or Distribution System Operator Instructions To avoid your application being rejected please read and follow these instructions carefully. 1. Complete ALL items in SECTION I and II ONLY. PRINT IN PEN OR TYPE ALL INFORMATION* 2. Include copies of all course completion certificates. 3. BE SURE TO SIGN AND DATE YOUR APPLICATION* FAILURE TO COMPLETE THIS APPLICATION FULLY WILL CAUSE IT TO BE REJECTED AND RETURNED AS INCOMPLETE* I. .

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Keywords relevant to DOH-352

  • Applicant
  • renewal
  • II
  • Certificates
  • corrections
  • Completion
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