"Certified Operator Contact Information Update Form" - Connecticut

Certified Operator Contact Information Update Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Certified Operator Contact Information Update Form" - Connecticut

1406 times
Rate (4.7 / 5) 84 votes
Operator Contact Information Update Form
Certified
PURPOSE: This form is to be used by CT DPH Certified Operators to change / update their contact information
(i.e. address, phone, fax, cell, e-mail, name change).
INSTRUCTION: Fill out this form and return it to the address below to make any contact information changes.
Certified Operators must maintain 1 main public/contact mailing address with the CT DPH. You must print clearly –
any form that cannot be read will be returned or may result in information / documentation not being delivered to you.
Maintaining your contact information will ensure that you receive your certificate renewal application.
For name changes you must submit with this form legal documentation of name change.
Write/Type in CT DPH Certification number(s);
List Certification #
List Certification #
Treatment Plant Operator
DWPO.
. Backflow Prevention
DWBT.
.
Distribution System Operator
DWDO.
.
Device Tester
Small Water System Operator
DWSO.
. Cross Connection
DWCI.
.
Survey Inspector
OPERATOR CONTACT INFORMATION
First Name
M. Initial
Last Name
Company Name (can be left blank)
Address Line 1 (St. Address or P.O. Box #)
Address Line 2 (Apt. #, Suite #, Box # - can be left blank)
Telephone
Zip Code
Fax
Town
Cell
State
Email
Attestation Signature
I attest that the information provided above is truthful and complete.
Signature:_____________________________________________ Date: ________________
dph.opcontact@ct.gov
This completed form must be returned to:
or mail to:
CT DPH, Drinking Water Section
410 Capitol Avenue, MS#51WAT
P.O. Box 340308
Hartford, Connecticut 06134-0308
Phone: (860) 509-8000 • Fax: (860) 509-7184
www.ct.gov/dph
Affirmative Action/Equal Opportunity Employer
Operator Contact Information Update Form
Certified
PURPOSE: This form is to be used by CT DPH Certified Operators to change / update their contact information
(i.e. address, phone, fax, cell, e-mail, name change).
INSTRUCTION: Fill out this form and return it to the address below to make any contact information changes.
Certified Operators must maintain 1 main public/contact mailing address with the CT DPH. You must print clearly –
any form that cannot be read will be returned or may result in information / documentation not being delivered to you.
Maintaining your contact information will ensure that you receive your certificate renewal application.
For name changes you must submit with this form legal documentation of name change.
Write/Type in CT DPH Certification number(s);
List Certification #
List Certification #
Treatment Plant Operator
DWPO.
. Backflow Prevention
DWBT.
.
Distribution System Operator
DWDO.
.
Device Tester
Small Water System Operator
DWSO.
. Cross Connection
DWCI.
.
Survey Inspector
OPERATOR CONTACT INFORMATION
First Name
M. Initial
Last Name
Company Name (can be left blank)
Address Line 1 (St. Address or P.O. Box #)
Address Line 2 (Apt. #, Suite #, Box # - can be left blank)
Telephone
Zip Code
Fax
Town
Cell
State
Email
Attestation Signature
I attest that the information provided above is truthful and complete.
Signature:_____________________________________________ Date: ________________
dph.opcontact@ct.gov
This completed form must be returned to:
or mail to:
CT DPH, Drinking Water Section
410 Capitol Avenue, MS#51WAT
P.O. Box 340308
Hartford, Connecticut 06134-0308
Phone: (860) 509-8000 • Fax: (860) 509-7184
www.ct.gov/dph
Affirmative Action/Equal Opportunity Employer