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ELECTRONIC SAMPLE ENTRY (eSE) SUBSCRIBER AGREEMENT
IDEM – Drinking Water Branch
State Form 55656 (8-14)
100 N. Senate Ave.
Indiana Department of Environmental Management (IDEM)
MC 66-34
Indianapolis, IN 46204-2251
Office of Water Quality – Drinking Water Branch – Compliance Section
Telephone: 317-234-7435
Fax: 317-234-7436
INSTRUCTIONS:
1. Complete electronic Sample Entry (eSE) Subscriber Agreement.
E-mail:
dwbmgr@idem.in.gov
2. Retain a copy of the eSE Subscriber Agreement form for your records.
3. Submit the eSE Subscriber Agreement form to IDEM.
 
 
electronic Sample Entry (eSE) Subscriber Agreement Number: ___________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IDEM USE ONLY
 
This page can be used for agreements issued by: Indiana Department of
Environmental Management (IDEM)
 
Purpose:
The eSE Subscriber Agreement should be used by laboratories that process drinking water
sampling results that would like to report the sampling results electronically using Indiana
Department of Environmental Management’s (IDEM) electronic Sample Entry (eSE) application;
it may also be used to change/update status information from a previously submitted
Agreement. Submission of drinking water sampling results electronically is an alternative to
using paper forms to fulfill reporting requirements specified under Indiana Administrative Code
327 IAC 8-2-13.
 
A. Subscriber Information
 
The subscriber is the individual that intends to sign the drinking water sampling result
submission file and signs this subscriber agreement.
 
Registrant E-mail Address (ID):
_______________________________________
Registrant Name: _______________________________________________
Registrant Telephone Number: ____________________________________
Registrant Organization: _________________________________________
Lab Certification Identification Number: ____________________________
 
 
B. Subscriber Signature
 
The subscriber is the registrant that submits this agreement to request to electronically
sign/submit drinking water sampling results on behalf of the organization. The subscriber is
either the Certifier denoted in Section C or is an individual to whom the Certifier delegates
signatory authority to submit/sign for drinking water sampling results on behalf of the
organization.
 
I, ________________________, am authorized by the signatory authority named in Section C
of this document, to enter into this agreement for ___________________________________.
 
 
 
 
 
 
 
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Reset Form
ELECTRONIC SAMPLE ENTRY (eSE) SUBSCRIBER AGREEMENT
IDEM – Drinking Water Branch
State Form 55656 (8-14)
100 N. Senate Ave.
Indiana Department of Environmental Management (IDEM)
MC 66-34
Indianapolis, IN 46204-2251
Office of Water Quality – Drinking Water Branch – Compliance Section
Telephone: 317-234-7435
Fax: 317-234-7436
INSTRUCTIONS:
1. Complete electronic Sample Entry (eSE) Subscriber Agreement.
E-mail:
dwbmgr@idem.in.gov
2. Retain a copy of the eSE Subscriber Agreement form for your records.
3. Submit the eSE Subscriber Agreement form to IDEM.
 
 
electronic Sample Entry (eSE) Subscriber Agreement Number: ___________
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IDEM USE ONLY
 
This page can be used for agreements issued by: Indiana Department of
Environmental Management (IDEM)
 
Purpose:
The eSE Subscriber Agreement should be used by laboratories that process drinking water
sampling results that would like to report the sampling results electronically using Indiana
Department of Environmental Management’s (IDEM) electronic Sample Entry (eSE) application;
it may also be used to change/update status information from a previously submitted
Agreement. Submission of drinking water sampling results electronically is an alternative to
using paper forms to fulfill reporting requirements specified under Indiana Administrative Code
327 IAC 8-2-13.
 
A. Subscriber Information
 
The subscriber is the individual that intends to sign the drinking water sampling result
submission file and signs this subscriber agreement.
 
Registrant E-mail Address (ID):
_______________________________________
Registrant Name: _______________________________________________
Registrant Telephone Number: ____________________________________
Registrant Organization: _________________________________________
Lab Certification Identification Number: ____________________________
 
 
B. Subscriber Signature
 
The subscriber is the registrant that submits this agreement to request to electronically
sign/submit drinking water sampling results on behalf of the organization. The subscriber is
either the Certifier denoted in Section C or is an individual to whom the Certifier delegates
signatory authority to submit/sign for drinking water sampling results on behalf of the
organization.
 
I, ________________________, am authorized by the signatory authority named in Section C
of this document, to enter into this agreement for ___________________________________.
 
 
 
 
 
 
 
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By submitting this application to IDEM, I, ________________________, have read, understood,
and accept the terms and conditions of this subscriber agreement (see section E). I certify under
penalty of law that I have personally examined and am familiar with the information in this
application and that to the best of my knowledge, the information is true, accurate, and complete.
 
 
         
 
 
 
 
 
 
 
Subscriber Signature
Date (month, day, year)
 
C. Signatory Authorization
 
The signatory authority is the individual identified with the authority to submit and electronically
sign for sampling result files.
 
I, ____________________________, have the authority to enter into this Agreement on behalf of
________________________________. I request IDEM grant the ability to submit drinking water
sampling results from __________________________________ to IDEM using eSE application.
 
 
Certifying Authority Signature
Date (month, day, year)
 
 
 
Certifying Authority Telephone Number
Certifying Authority E-mail Address
 
 
 
D. Inactivation/Removal
 
Registrant must indicate reason for inactivation in Section D of the form. This is to inform IDEM
authority whether the registrant is switching back to paper reporting of sample results, is no
longer an employee or in business, or has a temporary reason for inactivation.
 
Where to Submit Sample Entry (eSE) Subscriber Agreement:
Print and mail the completed subscriber agreement to below individual at below address. You
should retain a hard copy.
 
Attn: Drinking Water Branch Compliance Section Chief
Indiana Dept of Environmental Management
100 North Senate Avenue (66-34)
Indianapolis, IN 46204
 
Questions?
 
For help or questions please contact IDEM at (317) 234-7435 or dwbmgr@idem.IN.gov. You will
receive a confirmation e-mail from the eSE System Administrator when your application has
been processed and approved. Thank you for helping us reduce paper use by choosing to
electronically submit your drinking water sampling results.
 
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Reasons to Fill Out electronic Sample Entry (eSE) Subscriber Agreement:
 
To request use of electronic reporting for drinking water sampling results, the person
authorized to sign and submit drinking water sampling result submission files must
sign this document as the Signatory Authority in Section C of this document.
If the Signatory Authority (named in Section C) plans to electronically submit/sign for
drinking water sampling result submission files through eSE, this person will also
sign as the Subscriber (named in section B).
If the Signatory Authority plans to have someone else sign and submit the drinking
water sampling result submission files, this person must be a duly authorized
representative of the organization and the duly authorized representative must sign
as the Subscriber (see section B).
If the authority to electronically sign for a sample result is to be delegated to multiple
Subscribers, each Subscriber needs to submit and sign a separate Subscriber
Agreement.
This Subscriber Agreement cannot be used to register multiple eSE registrants.
 
E. Terms and Conditions
 
1. PURPOSE: The intent of this agreement is to create legally binding obligations on the
parties using eSE to report electronic drinking water sampling results to ensure the
Certifier (in this document, Certifier refers to signers of this document – both Signatory
Authority and Subscriber) agrees to: (1) Maintain the confidentiality and protect the
electronic signature from unauthorized use or compromise and follow any procedures
specified by the Regulatory Authority for this purpose; (2) Be held as legally bound,
obligated, or responsible by use of the assigned electronic signature as by hand-written
signature.
2. VALIDATION: This Agreement has been executed by the parties to evidence their
mutual intent to follow procedures to use electronic transmission to report drinking water
sampling results. Acceptance and execution of this agreement by IDEM shall be
evidenced by the issuance of a personal and unique e-mail ID to the Certifier. Electronic
signatures under this agreement shall have the same force and effect as a written
signature. Pen and ink signatures will remain on file with IDEM.
3. RECEIPT: A submission file shall be deemed to have been received by IDEM when it is
accessible by IDEM, can be fully processed and is syntactically correct to the specified
electronic transfer protocol.
4. VERIFICATION: On receipt of this document, the eSE-Verify Administrator processes it
to make it accessible to IDEM Authority and the Certifier. The Certifier is responsible for
the content and accuracy of each Submission File.
5. SIGNATURE: The Certifier shall adopt as his/her electronic signature any unique
Registrant e-mail ID assigned by IDEM following acceptance of this Agreement. The
Certifier agrees that any such Signature affixed to or associated with any transmitted
Submission File is sufficient to verify each party originated and possessed the requisite
authority both to originate the submission and to verify accuracy of its content.
6. SECURITY: The parties shall take reasonable actions to implement and maintain
security procedures to ensure the protection of transmissions against the risk of
unauthorized access, alteration, loss or destruction including but not limited to protecting
the secrecy of passwords and electronic signatures.
7. USE OF UNIQUE E-MAIL ID: Each Certifier shall be either the Registrant or a person
identified by the Registrant as a representative authorized for signatory purposes for
each organization (such as laboratory) from which information is being reported. If a
 
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registrant’s unique e-mail ID credentials have been compromised or if there is evidence
of potential compromise, this results in deactivation of the unique e-mail ID. IDEM also
inactivates registrant’s unique e-mail ID where the Certifier is no longer the authorized
representative. Each Certifier expressly agrees the IDEM Authority may act immediately
and unilaterally in a decision to deactivate use of a unique e-mail ID by a Certifier when it
is necessary to ensure the authenticity and integrity of eSE file submissions or where
there is actual or apparent violation of this agreement.
8. INABILITY TO SUBMIT FILES ELECTRONICALLY: No party shall be liable for failure to
submit electronic files, where the failure results from any act or cause beyond the party’s
control; except the Certifier is required to continue to submit sampling results by other
means. In the event that electronic submission of drinking water sampling result files is
not possible, it is the responsibility of the Certifier to submit paper copies.
9. TERMINATION AND RENEWAL: The agreement may be terminated by either Party.
On termination of this agreement, the ability to submit electronic sampling results using
the IDEM eSE application is also terminated. This subscriber agreement becomes
effective on notification of approval of IDEM to the Certifier. IDEM will normally provide
notification of the effective date, but if no date is provided, the effective date is the date
the Certifier receives notice of approval of the Agreement. This Subscriber Agreement
will continue until modified by mutual consent unless terminated within sixty (60) days
written notice by any party. Registrant must resubmit this form if he/she finds it
necessary to change information supplied when completing eSE-Verify’s online profile.
10. GOVERNING LAW: This Agreement shall be governed by and interpreted in accordance
with Indiana Administrative Code 327 IAC 8-2-13, Indiana Code (IC) 13-30-10-1 and US
CFR 3.
11. AGREEMENT:
I agree
i.
To protect my account and password from compromise, not allow anyone
else to use my account, not to attempt to use or create automated log-in
scripts for my electronic signature credentials, and not share my
password with any other person;
ii.
To change my password if I believe it becomes known to any other
person;
iii.
To promptly report to IDEM authority any evidence of the loss, theft, or
other compromise of my account or password within one business day;
iv.
The certifying authority shall notify IDEM in writing if I terminate my
employment or am reassigned so that I no longer may represent my
organization as a Certifier – with notification to IDEM authority occurring
as soon as this change occurs;
v.
To report any evidence of discrepancy between submission file and what
eSE application receives;
vi.
That in no event will IDEM authority be liable to me or my employer for
any special, consequential, indirect or similar damages, including any lost
profits or lost data arising out of the use of or inability to use the software
or of any data supplied even if IDEM or anyone else has been advised of
the possibility of such damages, or for any claim by any other party.
 
I understand I will be held as legally bound, obligated, and responsible by the
electronic signature created as a handwritten signature. I understand under Indiana
Code 13-30-10-1 that criminal penalties apply to a person who knowingly or
intentionally falsely certifies a record regardless of whether the person uses
electronic submissions or paper documents to accomplish this action.
 
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Checklist for use by IDEM only.
 
Check
Activity
Staff Name
Date
 
IESA Form Received by IDEM
 
 
IDEM Approves IESA
 
 
Notification to Certifying Authority and
 
 
Registrant
 
Terminated?
 
 
 
 
 
 
 
 
 
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