APPLICATION
for
MEMBERSHIP OR CHANGE OF MEMBERSHIP STATUS
in the
WASHINGTON WASTEWATER COLLECTION PERSONNEL ASSOCIATION

Section A
Name of Applicant ___________________________________________________________
(Last)                  (First)           (Middle or Business Name)
Address:              
(To which all WWCPA correspondence shall be sent)
________________________________________________________________

________________________________________________________________

________________________________________________________________
(City)                  (State)                              (Zip Code)

Email Address:
_______________________________________________

Telephone Numbers:               
Work:  
______(__________)_______________________________________
Home: 
______(__________)_______________________________________

Date of Birth (Certified & Associate Memberships only)
 _____________________, 19________

Section B	TYPE OF MEMBERSHIP APPLICATION

1.	Certified Membership (Complete Sections A,C,D,E & G)
	Wastewater Collection Specialist‑    in Training (WWC‑    SIT)
	Wastewater Collection Specialist I (WWC‑    I)
	Wastewater Collection Specialist II (WWC‑    II)
	Wastewater Collection Specialist III (WWC‑    III)
	Wastewater Collection Specialist IV (W~WC‑    IV)

b.	Associate Membership (Complete Sections A,C,D,E & G)
c.	Corporate/Institutional Membership (Complete Sections A,F & G

Section C
2.	Are you now, or have you previously been, a Member of the Washington Wastewater Collection Personnel ASSOCIATION? ___________________________________________

If so, what (is/was) your membership status? ___________________________________________
Name:_______________________________________

In what year did you last hold membership? _________________________________________
b.	Are you currently certified or licensed under any other related program in
	Washington or other states? Give details _____________________________________________________________________

        _____________________________________________________________________

                 _____________________________________________________________________
3.	List any related organizations in which you hold memberships. _____________________________________________________________________

           _____________________________________________________________________

                 _____________________________________________________________________

	Section D   EDUCATION AND TRAINING (Certified & Associate Memberships only)

a.	Primary and Secondary Education
	Circle highest grade completed.	6 ‑     7‑     8 ‑     9 ‑     10 ‑     11 ‑     12
	Name and location of last high school attended?___________________________________________
	Did you graduate?________If not, and you hold a GED certificate, note here________and indicate where it was issued?___________________________________________________

b.  Additional General Education (Note sections D‑    c and D‑    d following)

College or other Institutions attended	Dates
(from/to)	Major
Subjects	Credits Earned
(Specify quarter Earned or semester hours)	Degrees
Earned
(if any)	
	/				
	/				
	/				
	/				
Note:	Provide transcripts of college work if applying for Certified Membership at WWC III or WWC IV levels.

Name:_______________________________________

4.	Specialized Education in Wastewater or Water Technology

Name of College or Sponsor of Training	Name of Course and/or Subjects*	Dates of Attendance	Class Hours Attended in
Lecture = L
Lab or Drill = D
On Job Training = OJT	Credit Hours
Cont. Ed. Uni
(CEU's)
Degree or Certificate	
		/			
		/			
		/			
		/			
		/			
		/			
		/			

*For multi‑    course coordinated vocational training programs and for education-experience equivalency evaluation as provided in By‑    Laws Section 7.6‑    b or‑    c, provide transcripts of college work. Provide catalog course descriptions of all vocational courses listed on such transcripts.

d.	Discuss on attached sheets any additional education or training that you feel should be considered in determining your qualifications. This would include special schools in military service, correspondence courses, apprenticeships, etc. Give as much detail as possible on what, where, when, how long etc. The burden of documentation of such training is yours.
Name:___________________________________

Section E    EXPERIENCE (Certified & Associate Memberships Only)

List, using Back page & attached pages as necessary, all experience that you feel should be evaluated to meet requirements for certification. Start with current position or most recent experience and progress backwards. Include such information as the employer’s name, job or position title, period of employment, duties and name of your immediate supervisor for each such position listed. See section 7.0 for experience requirements.

Section F    BUSINESS or VOCATIONAL ACTIVITY (for Associate or Corporate/Institutional Memberships only)

Nature of Activity of Business (or of Employer for Associate Members)

·	Municipal Wastewater Utility/Department
·	Employee Union or Association
·	Equipment or Materials Manufacturing Vendor
Name:_______________________________________
·	Engineering/Planning Firm
·	Sewer District
·	Educational Institution
·	Construction Firm
·	State/Federal Agency
·	Consumer or Consumer Group
·	Other (describe) _________________________________________________________________________

Briefly state the nature of, or reason for, your interest in the field of wastewater collection. ________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Section G
In signing this application, I do affirm that all facts and information presented herein, including any attachments, are true and correct to the best of my knowledge. I also grant my permission for any former employer, employment associate or educational associate to examine the facts and claims herein for purposes of verification of such facts or claims and further agree to hold the Washington Wastewater Collection Personnel ASSOCIATION blameless for allowing such examination for verification.

Please circle one either 1 or 2:

5.	*I (we) do grant permission;
      for use of the information described below.
	
6.	*I (we) do not grant permission; 

*To have my/our name, address, employers name, phone numbers, type of membership and certification level (if for Certified Membership) appear in a published ASSOCIATION Directory providing that the Directory does not indicate test scores and does not identify any applicants who may fail to qualify for membership.

Signature ______________________________________ 

Date ________________________________

For (Company name, if applicable)______________________________________________________

Employment
(start with current position)
Dates
From/to	Employer                           
Name & address   	Name of Supervisor
	Job Title
	Job Responsibilities
(describe in detail: Include
types of equipment used)