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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 System Operator DOH-352 (9/15) Page 1 of 2 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 II. Renewal Training Credits – Summarize below all training received towards renewal in the past three years. YOU MUST COMPLETE THIS SECTION IN ITS ENTIRETY FOR THIS APPLICATION TO BE PROCESSED PLEASE ENTER ANY ADDRESS CORRECTIONS IN THE SPACE BELOW Home Phone No. Home Email Address Employer Name Employer Address Work Phone No. Work Email Address County of Employment Are you a veteran? yes no Are you a contract operator? yes no Course (Title) Dates Contact Hours Approved Training Course # Training Provider 1 2 3 4 5 6 7 8 9 10 Signature: Date: Grade Effective Date Expiration Date BWSP Use Only ---PAGE BREAK--- DOH-352 (9/15) Page 2 of 2 Course (Title) Dates Contact Hours Approved Training Course # Training Provider 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30