The Commonwealth of Massachusetts
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES
1000 Washington Street, Suite 710 Boston, Massachusetts 02118
The following documentation must be submitted with this application.
The Board will not review this application without the required information.
Incomplete applications will be returned to the applicant.
If applying for multiple licenses, you must submit separate applications for each license
and separate documentation must be included in each application
a 2” x 2” color passport photo
the ABC score report verifying I have passed the exam
“Proof of Education” documentation required on page 3 of this application
All applicants with greater than a High School Diploma, GED or Equivalent must submit
proof of such education with this application. All candidates submitting post-secondary
education must include a copy of their college transcript.
“Proof of Experience” documentation required on page 4 of this application
All applicants seeking a certificate for “Full” status must include a copy of their job
description obtained directly from their employer or a letter from their supervisor detailing
their duties and responsibilities. Candidates must include verification from their
employer(s) of years of service and hours worked per week.
Training Course Certificate of Completion
All applicants for Grade 2 or higher level exams must submit a copy of the Certificate of
Completion issued by the training organization to demonstrate that the applicant has
successfully completed the required training course(s) for the grade and classification of
the certificate being applied for. The required training course(s) include the following:
VSS, D1, or T1 No training required.
D2, D3, or D4 Applicant must complete Basic Distribution Training with provider
approved by the Board.
T2 Applicant must complete Basic Treatment Training Course with provider approved by
the Board.
T3 or T4 - Applicant must complete Advanced Treatment Training Course with provider
approved by the Board.
Applicants may apply for a waiver from the training requirements if they meet
criteria established by the Board. If an applicant has been granted a waiver, the
applicant must submit a copy of the approved waiver.
“CORI Acknowledgement Form including the completion of either Section A or Section B
Signed Code of Ethics Agreement
$70.00 non-refundable application/license fee payable to the Commonwealth of
Massachusetts
VETERANS ONLY: a copy of my DD form 214
Mail your completed application to:
Board of Certification of Operators of Drinking Water Supply Facilities
1000 Washington Street Suite 710
Boston, MA, 02118-6100
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
FOR BOARD USE ONLY
License #:____________
Type:________________
Cash Date:____________
The Commonwealth of Massachusetts
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES
1000 Washington Street, Suite 710 Boston, Massachusetts 02118
OPERATOR CERTIFICATION APPLICATION
NOTE: $70.00 Application Fee non-refundable payable to the Commonwealth of Massachusetts
APPLICANT INFORMATION
Application Date:_____________
Last Name: ___________________________________First Name: _____________________Middle Initial:_____
Former Name, Also Known as, if applicable:
Other Last Name Other First Name Other Middle Initial:
Gender: Male: Female: Prefer not to answer:
Mailing Address: _____ _____________________________ ______________________ _____ _________
Number Address City/Town State Zip Code
Home Phone: _______________ Cell Phone: _______________ Email: __________________________________
Please note: EMAIL is the primary means of contact for routine correspondences during the application process.
Social Security Number (Mandatory): ________________________________ Date of Birth: ________________
Pursuant to G.L. c.62C, s. 47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the
Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with the
tax laws of the Commonwealth.
Has any disciplinary action been taken against you by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Are you the subject of pending disciplinary actions by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in the
United States or any country or foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever applied for and been denied a professional license in the United States or any country or foreign
jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever been convicted of, or admitted to, a felony or misdemeanor in the United States or any country or
foreign jurisdiction? Yes: No:
If yes, please state the details (use a separate sheet if necessary):
__________________________________________________________________________________________
List all professional licenses/certifications you have held in the United States, or any country or jurisdiction, and the
state/jurisdiction from which the license/certification was originally issued.
Type of License: Jurisdiction: License Number:
Type of License: Jurisdiction: License Number:
MILITARY STATUS
Please check the appropriate box: Active Duty: Spouse: Veteran: Not Applicable:
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
INSTRUCTIONS
1. You must have passed an operator examination before applying for certification
2. Read all instructions and questions before filling out the application
3. Answer all questions on this form. If a question is not applicable, draw a line in that space or write N/A.
Incomplete applications will be returned.
4. Make additional copies of page 4 to submit if you are including multiple relevant employment
5. Mail your completed application package to the address at the bottom of page 1
A. OPERATOR GRADE INFORMATION
Operator grade for which this application is being submitted:
CHECK ONLY ONE ITEM IN BOX 1. AND ONE ITEM IN BOX 2.
Only one license request is allowed per application
D1 D2 D3 D4
T1 T2 T3 T4 Full In-Training
VSS
VND-D1 VND-D2
VND-T1 VND-T2 VND-T3 VND-T4
B. CURRENT GRADE STATUS
List all FULL Massachusetts Drinking Water certifications you currently hold
Grade: ______ License Number: ____________ Grade: ______ License Number: ____________
Grade: ______ License Number: ____________ Grade: ______ License Number: ____________
C. EDUCATION
1. High School Diploma GED or Equivalent
2. College/University Degree: AS BS MS AA BA MA PHD
3. Certificate: In what discipline? _______________________________________________________
4. Years of acceptable college credit without a degree: ____________
All applicants with greater than a High School Diploma, GED or Equivalent must submit proof
of such education with this application. Candidates with a BS, AS or MS must submit a copy
of their diploma or college transcript. All other degrees or non-degree college experience
must include a copy of the transcript.
This application will only be reviewed if all documentation listed
on the front page has been included with your submittal.
Incomplete forms will be returned
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
1.
2.
Please make additional copies of this page and include them with your application in order to provide
additional employment history necessary to meet the experience requirements associated with the
license you are applying for.
D. EXPERIENCE
You must include all of the experience items from the front page of this
application in order to be reviewed. Incomplete applications will be returned
1. Position
_________________________________________________ _________________ _________________
Title Date Position Began Date Position Ended
____________________________________________ ________________________________________
Employer’s Name Address
_______________________________ ___________________________ _________________________
City/Town Supervisor’s Name Title
________________________ ____________________________________________________________
Supervisor’s Phone Supervisor’s email address
2. Public Water Supply Information
Name of Public Water System: ____________________________________________________________
Public Water System ID Number: ______________________
DEP classification of the Public Water System.
(If not sure, please verify by contacting your local DEP Regional Office.)
DI DII DIII DIV VSS TI TII TIII TIV
3. List your duties and responsibilities (please be specific):
Distribution:
How much of your time is spent on Distribution duties each day? ______ hours per day _____ days per week
List your specific Distribution duties in space provided below:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Treatment:
How much of your time is spent on Treatment duties each day? ______ hours per day _____ days per week
List your specific Treatment duties in space provided below:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name of Treatment facility: ________________________________________________________________
Type(s) of Treatment process: _____________________________________________________________
Types of chemicals used: _________________________________________________________________
Date facility was placed online: __________
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
The Board is certified by the Criminal History Systems Board {ID#MAREG G} to access data about convictions and pending
criminal cases. Those records and other Federal and professional records may be checked as part of your licensing
process. No records are automatic disqualifiers; you will be given an opportunity for a limited appearance before the Board of
Certification of Operators of Drinking Water Supply Facilities.
CERTIFICATION OF APPLICANT
I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application
for licensure is truthful and accurate. I understand that the failure to provide accurate information may be grounds
for the Massachusetts Board of Certification of Operators of Drinking Water Supply Facilities to deny me the right to
sit as a candidate or to suspend or revoke a license issued to me in accordance with Massachusetts Law. I further
attest that, pursuant to G.L. c.62C, §49A, to the best of my knowledge and belief, I have complied with all laws of
the commonwealth relating to taxes, reporting of employees and contractors, and withholding and remitting of child
support.
Signature of Applicant ___________________________________________________ Date ______________
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
Please affix
2” x 2”
Passport Photo Here
MASSACHUSETTS BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES
PROFESSIONAL CODE OF ETHICS FOR WATER SYSTEM OPERATORS
In order to establish and maintain a high standard of integrity, skills and practice in the profession of water system
operations and to safeguard the life, health, property, and welfare of the public, the following rules of professional
conduct are adopted by every person holding a license as a water system operator in Massachusetts. All persons
licensed in Massachusetts are required to have knowledge of the existence of these rules of professional conduct
and understand them.
1. The water systems operator shall, at all times, recognize his or her primary obligation is to protect the
safety, health, and welfare of the public in the performance of his or her duties. If his or her judgement is
overruled under circumstances where the safety, health, and welfare of the public are endangered, he or
she shall inform his or her employer of the possible consequences and notify such other proper authority of
the situation, as may be appropriate.
2. The water systems operator shall accept and perform water operations assignments only when qualified by
education, or experience, in the specific technical area and levels of water operations involved. The water
systems operator may accept an assignment requiring education, or experience outside of his or her own
field of competence, but only under the direct supervision of licensed, qualified co-workers, consultants, or
employees.
3. The water systems operator shall be completely objective and truthful in all professional reports,
statements, or testimony. He or she shall include all relevant and pertinent information in such reports,
statements, or testimony.
4. The water systems operator shall avoid conflicts of interest with his or her employer, or customer, but,
when unavoidable, the water system operator shall promptly disclose the circumstances to his or her
employer, or customer, of any business association, interest, or circumstances which could influence his or
her judgment, or the quality of his or her work. The water system operator shall not review, or influence the
decision of his or her employees’ work for any public body on which he or she may serve.
5. The water system operator shall not solicit, or accept financial or other valuable items from material, or
equipment suppliers for specifying their product.
6. The water system operator shall not solicit, or accept gratuities from contractors, or other parties dealing
with his or her customers, or employer, in connection with work for which he, or she is responsible.
7. The water system operator shall not falsify his or her academic or professional qualifications. He or she
shall not misrepresent or exaggerate his or her degree of responsibility in prior assignments, duties, or
accomplishments to enhance his or her qualifications and work.
8. The water system operator shall not knowingly associate with or permit the use of his or her name or
employer’s name in the operation of a public water system which he or she knows or has reason to believe
is engaging in business or professional practices of fraudulent or dishonest nature.
9. If the water system operator has knowledge or reason to believe that another person, or water purveyor,
may be in violation of any of these rules, he or she shall present such information to the Massachusetts
Board of Certification of Operators of Drinking Water Supply Facilities and the Massachusetts Department
of Environmental Protection in writing and shall cooperate with the regulatory agency in furnishing
information, or assistance as may be required by the agency.
I have read and understood the above Professional Code of Ethics for Water System Operators and hereby agree to adhere
to said code in performance of my duties. I further understand that failure to adhere to said code may result in disciplinary
action and/or suspension or revocation of the license(s).
_________________________________________ ____________________________________________ ________________
Name of Applicant (Print) Signature of Applicant Date
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PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/dw
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
__________________________________________________________ _______________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_____________________________________________ _________________________________
DPL Board of Registration License Type
NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (An asterisk (*) denotes a required field)
_______________________ ______________________ _______________________ ____
*Last Name *First Name Middle Name Suffix
________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________ ____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
Sex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
__________________________________ ______________________ _________ _____________
Street Number & Name City/Town State Zip Code
__________________________________ ______________________ _________ _____________
Street Number & Name City/Town State Zip Code
SECTION A: VERIFICATION BY DPL EMPLOYEE: To be filled out by DPL employee only if the
applicant is submitting this form in person
I hereby certify that I verified the identity of the above-referenced subject by reviewing the following
form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee Date
SECTION B: VERIFICATION BY NOTARY: To be filled out by Notary if the applicant is filling in this
form while not in the presence of a DPL employee
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the person whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
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