Backflow Assembly Tester Certification Application

Step 1

Fill out the application form completely (official correspondence will be mailed to you at the address you provide on this page).

Step 2

New applicants must provide a notarized copy of his/her citizenship form, INCLUDING GOVERNMENT PICTURE I.D.

Visit the Payment Portal

^*Application Type:

Initial CertificationRenewalReciprocity

Personal Information

^*First Name:

Middle Name:

^*Last Name:

^*Email:

^*Phone:

^*Mailing Address:

^*City:

^*State:

^*ZIP Code:

Employment

^*Current Employer (no abbreviations):

^*Work Phone:

Course Information

^*Date of Course:

^*Instructor(s):

^*Location of Course:

^*Length of Course (hours/days):

Would you like to be COMMERCIALLY AVAILABLE to test backflow prevention assemblies?

Yes

Contact Phone:

Continuing Education Units (CEUs)

DDW CEU:

Yes

Water Operator Certification #:

DOPL CEU:

Yes

Name as on license:

DOPL License #:

Agree and Submit

By clicking the Submit button, you certify that the above information is correct and complete. You understand that any info might be verified by Drinking Water Staff

I Agree

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