Form A465-1944ALTLIC "Alternative Onsite Sewage System Installer - License Application" - Virginia

What Is Form A465-1944ALTLIC?

This is a legal form that was released by the Virginia Department of Professional and Occupational Regulation - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 8, 2021;
  • The latest edition provided by the Virginia Department of Professional and Occupational Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form A465-1944ALTLIC by clicking the link below or browse more documents and templates provided by the Virginia Department of Professional and Occupational Regulation.

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Download Form A465-1944ALTLIC "Alternative Onsite Sewage System Installer - License Application" - Virginia

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Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-8595
www.dpor.virginia.gov
Board for Waterworks and Wastewater Works Operators and Onsite Sewage System Professionals
ALTERNATIVE ONSITE SEWAGE SYSTEM INSTALLER - LICENSE APPLICATION
Fee $100.00
A check or money order payable to the TREASURER OF VIRGINIA,
or a completed
credit card insert
must be mailed with your application package.
APPLICATION FEES ARE NOT REFUNDABLE.
Select the
one license type you are applying for:
X
License Types:
Trans
A. Journeyman Alternative Installer
Do not hold a Virginia Installer license
1210
Currently hold a Virginia Journeyman Conventional Installer license
6210
Currently hold a Virginia Master Conventional Installer license
6215
B. Master* Alternative Installer - select one of the following:
Do not hold a Virginia Installer license
1305
Currently hold a Virginia Journeyman Conventional Installer license
6305
Currently hold a Virginia Master Conventional Installer license
6305
Currently hold a Virginia Journeyman Alternative Installer license
6305
* Master applicants will be authorized to take the applicable examination upon approval of
this application.
Provide your current or expired onsite sewage system installer license (if applicable)?
Virginia License Number
1
9 4 4
Expiration Date
1.
Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle
Generation
2.
Provide at least one of the following identification numbers :
Social Security Number and/or
-
-
Virginia DMV Control Number
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
3.
Date of Birth
(Must be at least 18 years of age.)
MM/DD/YYYY
4.
Maiden or Former Name(s)
5.
Mailing Address (PO Box accepted)
The mailing address will be
printed on the license.
City
State
Zip Code
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
1944
USE
ONLY
A465-1944ALTLIC-v2
Board for Waterworks & Wastewater Works Operators & Onsite Sewage System Professionals/ALTER INSTAL LIC APP
12/08/2021
Page 1 of 3
Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-8595
www.dpor.virginia.gov
Board for Waterworks and Wastewater Works Operators and Onsite Sewage System Professionals
ALTERNATIVE ONSITE SEWAGE SYSTEM INSTALLER - LICENSE APPLICATION
Fee $100.00
A check or money order payable to the TREASURER OF VIRGINIA,
or a completed
credit card insert
must be mailed with your application package.
APPLICATION FEES ARE NOT REFUNDABLE.
Select the
one license type you are applying for:
X
License Types:
Trans
A. Journeyman Alternative Installer
Do not hold a Virginia Installer license
1210
Currently hold a Virginia Journeyman Conventional Installer license
6210
Currently hold a Virginia Master Conventional Installer license
6215
B. Master* Alternative Installer - select one of the following:
Do not hold a Virginia Installer license
1305
Currently hold a Virginia Journeyman Conventional Installer license
6305
Currently hold a Virginia Master Conventional Installer license
6305
Currently hold a Virginia Journeyman Alternative Installer license
6305
* Master applicants will be authorized to take the applicable examination upon approval of
this application.
Provide your current or expired onsite sewage system installer license (if applicable)?
Virginia License Number
1
9 4 4
Expiration Date
1.
Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle
Generation
2.
Provide at least one of the following identification numbers :
Social Security Number and/or
-
-
Virginia DMV Control Number
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
State law requires every applicant for a license, certificate, registration or other authorization to engage in a business, trade, profession or occupation issued
by the Commonwealth to provide a social security number or a control number issued by the Virginia Department of Motor Vehicles.
3.
Date of Birth
(Must be at least 18 years of age.)
MM/DD/YYYY
4.
Maiden or Former Name(s)
5.
Mailing Address (PO Box accepted)
The mailing address will be
printed on the license.
City
State
Zip Code
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
1944
USE
ONLY
A465-1944ALTLIC-v2
Board for Waterworks & Wastewater Works Operators & Onsite Sewage System Professionals/ALTER INSTAL LIC APP
12/08/2021
Page 1 of 3
Check here if Street Address is the same as the Mailing Address listed above.
6.
Street Address (PO Box not accepted)
PHYSICAL ADDRESS REQUIRED
State
City
Zip Code
7.
Contact Numbers
Primary Telephone
Alternate Telephone
Fax
Email Address
8.
Email address is considered a public record and will be disclosed upon request from a third party.
9.
Are you applying for a journeyman alternative onsite sewage system installer license?
No
Yes
If yes, select one of the following requirements to qualify for licensure:
1.
Have 1 year of full-time experience* assisting with the installation of alternative onsite sewage
systems and currently an employee, owner, director or officer of a properly licensed Virginia
contractor with a sewage disposal system (SDS) specialty.
Virginia Contractor's License Number:
2
7
Required Documentation: Attach a completed Experience Verification Form.
2.
Have 2 years of full-time experience* assisting with the installation of alternative onsite sewage
systems.
Required Documentation: Attach a completed Experience Verification Form.
* Experience Verification Form must be verified by one or more of the following individuals: an alternative onsite soil evaluator, a master
alternative onsite sewage system installer, a professional engineer, or an authorized onsite soil evaluator certified by VDH before July 1,
2009.
Skip to question 12.
10.
Are you applying for a master alternative onsite sewage system installer license?
No
Yes
If yes, select one of the following requirements to qualify for the examination:
1.
Have 2 years of full-time experience* installing alternative onsite sewage systems and currently
an employee, owner, director or officer of a properly licensed Virginia contractor with a sewage
disposal system (SDS) specialty.
Virginia Contractor's License Number:
2
7
Required Documentation: Attach a completed Experience Verification Form.
2.
Have eighteen (18) months of full-time experience* installing alternative onsite sewage systems,
20 hours of Board approved training covering basic installation of alternative onsite sewage
systems and currently an employee, owner, director or officer of a properly licensed Virginia
contractor with a sewage disposal system (SDS) specialty.
Virginia Contractor's License Number:
2
7
Required Documentation: Attach a completed Experience Verification Form and a transcript or
certificate showing successful completion of approved training.
3.
Have 3 years of full-time experience* installing alternative onsite sewage systems and 20 hours
of Board approved training covering basic installation of alternative onsite sewage systems.
Required Documentation: Attach a completed Experience Verification Form and a transcript or
certificate showing successful completion of approved training.
A465-1944ALTLIC-v2
Board for Waterworks & Wastewater Works Operators & Onsite Sewage System Professionals/ALTER INSTAL LIC APP
12/08/2021
Page 2 of 3
4.
Have eighteen (18) months of full-time experience* installing alternative onsite sewage systems,
and hold an expired interim alternative onsite sewage system installer license, or a current
journeyman conventional, a master conventional or a journeyman alternative onsite sewage
system installer license.
Virginia expired Interim license number: 1
9
3
2
Required Documentation: Attach a completed Experience Verification Form.
* Experience Verification Form must be verified by one or more of the following individuals: a journeyman or master alternative onsite soil
evaluator, a master alternative onsite sewage system installer, a professional engineer, or an authorized onsite soil evaluator certified by
VDH before July 1, 2009.
11.
Are you requesting education and training substitution to qualify for licensure in accordance with 18VAC160-40-70
of the regulations?
No
Yes
If yes, complete the Education & Training Substitution Form
12.
Have you ever been subject to a disciplinary action taken by any (including Virginia) local, state or national regulatory
body?
No
Yes
If yes, complete the
Disciplinary Action Reporting
Form.
13.
A.
Have you ever been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the
United States of any felony? Any plea of nolo contendere shall be considered a conviction.
No
Yes
If yes, complete the
Criminal Conviction Reporting
Form.
B.
Have you been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the
United States of any misdemeanor within the last three years (except marijuana convictions)? Any plea of nolo
contendere shall be considered a conviction.
No
Yes
If yes, complete the
Criminal Conviction Reporting
Form.
14.
By signing this application, I certify the following statements:
I am aware that submitting false information or omitting pertinent or material information in connection with this
application will delay processing and may lead to license revocation or denial of license.
I will notify the Board of any changes to the information provided in this application prior to receiving the
requested license, certification, or registration including, but not limited to any disciplinary action or conviction of
a felony or misdemeanor (in any jurisdiction).
I authorize the Department to verify information concerning me or any statement in this application from any
person, or any source the department may contact. I also agree to present any credentials or documents
required or requested by the Department.
I authorize any federal, state or local government agency, current or former employer, or other individual or
business to release information which may be required for a background investigation.
I have read, understand and complied with all the laws of Virginia related to this profession under the provisions
of Title 54.1, Chapter 23, of the Code of Virginia and the Onsite Sewage System Professionals Licensing
Regulations of the Virginia Board for Waterworks and Wastewater Works Operators and Onsite Sewage
System Professionals.
Signature
Date
A465-1944ALTLIC-v2
Board for Waterworks & Wastewater Works Operators & Onsite Sewage System Professionals/ALTER INSTAL LIC APP
12/08/2021
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