Form ATP4 "Montana Continuing Education Credit Report Form" - Montana

What Is Form ATP4?

This is a legal form that was released by the Montana Department of Environmental Quality - a government authority operating within Montana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Montana Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form ATP4 by clicking the link below or browse more documents and templates provided by the Montana Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download Form ATP4 "Montana Continuing Education Credit Report Form" - Montana

268 times
Rate (4.6 / 5) 16 votes
Submit
MONTANA CONTINUING EDUCATION CREDIT REPORT FORM – ATP4
Mail original to DEQ – Keep copy for files
Instructions: The Operator should complete white portions and course provider(s) should complete the shaded
portions. The course provider must mail the completed form, no later than two weeks after the course is given, to
the Department of Environmental Quality Water/Wastewater Operator Certification Office at P.O. Box
200901, Helena, MT 59620-0901.
CEC INFORMATION: (Training Provider completes)
CECS EARNED:
WATER ____ ⋅ ____ ____ ____
WASTEWATER ____ ⋅ ____ ____ ____
TRAINER ____ ⋅ ____ ____ ____
OPERATOR INFORMATION: (operator completes – please print)
OPERATOR NUMBER: ____________________
CERTIFICATION CLASS AND TYPE: _______________
NAME: ______________________________________________________________________________________
SYSTEM OPERATED: _________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
CITY: _______________________________________
ZIP: _________________________________________
IS THIS A NEW ADDRESS: YES _______________
NO ________________
Shall we send application materials?
YES ____
NO ____
OPERATOR SIGNATURE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
COURSE INFORMATION: (Training Provider completes)
TITLE OF COURSE:
LOCATION OF COURSE:
DATE OF COURSE:
TYPE OF CERTIFICATION COURSE WAS APPROVED
WATER _________
WASTEWATER _______
NUMBER OF CREDITS APPROVED FOR COURSE: _______________________________________________
FACILITY-BASED TRAINING?
YES _____
NO _____
DUAL CEC COURSE?
YES ____
NO ____
ATP INFORMATION: (Training Provider completes)
ATP #:
APPROVED TRAINING PROVIDER: ________________________________________
SIGNATURE OF VERIFYING OFFICIAL: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
COMMENTS ON TRAINING COURSE: (for optional use by operator)
Submit
MONTANA CONTINUING EDUCATION CREDIT REPORT FORM – ATP4
Mail original to DEQ – Keep copy for files
Instructions: The Operator should complete white portions and course provider(s) should complete the shaded
portions. The course provider must mail the completed form, no later than two weeks after the course is given, to
the Department of Environmental Quality Water/Wastewater Operator Certification Office at P.O. Box
200901, Helena, MT 59620-0901.
CEC INFORMATION: (Training Provider completes)
CECS EARNED:
WATER ____ ⋅ ____ ____ ____
WASTEWATER ____ ⋅ ____ ____ ____
TRAINER ____ ⋅ ____ ____ ____
OPERATOR INFORMATION: (operator completes – please print)
OPERATOR NUMBER: ____________________
CERTIFICATION CLASS AND TYPE: _______________
NAME: ______________________________________________________________________________________
SYSTEM OPERATED: _________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
CITY: _______________________________________
ZIP: _________________________________________
IS THIS A NEW ADDRESS: YES _______________
NO ________________
Shall we send application materials?
YES ____
NO ____
OPERATOR SIGNATURE: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
COURSE INFORMATION: (Training Provider completes)
TITLE OF COURSE:
LOCATION OF COURSE:
DATE OF COURSE:
TYPE OF CERTIFICATION COURSE WAS APPROVED
WATER _________
WASTEWATER _______
NUMBER OF CREDITS APPROVED FOR COURSE: _______________________________________________
FACILITY-BASED TRAINING?
YES _____
NO _____
DUAL CEC COURSE?
YES ____
NO ____
ATP INFORMATION: (Training Provider completes)
ATP #:
APPROVED TRAINING PROVIDER: ________________________________________
SIGNATURE OF VERIFYING OFFICIAL: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
COMMENTS ON TRAINING COURSE: (for optional use by operator)