Student Application

PLEASE NOTE: You are going to need to have your certifications and licenses handy. So you can enter the certification and license number and its expiration date(THESE ARE REQUIRED FOR ALL CLASSES). You will need to email us all of your certifications and licenses upon completion of the application. If you are trying to submit your application, ALL boxes need to be completed before hitting submit. If you do not completely fill out your application and hit submit, the page will be refreshed with notes describing which sections need to be completed. Additionally, if you do not have a middle name, you do not have to enter an initial.

Resident Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zipcode:

Phone Number:

Email Address:

Employer Information

Company Name:

Position/Title:

Length in position:

Address:

City:

State:

Zipcode:

Phone Number:

Email:

Resident Acknowledgements

I acknowledge that I meet the prerequisite for this certification class:

Minimum of five years of water industry experience:

Current Certifications/Licenses - Required for ALL CLASSES. Enter numbers and expiration dates for all active certifications and licenses that you have.

Class Location:

Class Date:

Class Type:

Please type your first and last name to confirm your application:

Date:

After you hit submit, you will need to email us a copy of all of the licenses and certifications for the student that is applying. That email is backfloweducationgroup@gmail.com