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2. Name:*
4. Mailing Address:*
6. City, State & Zip:*
8. Email:*
10. 1.) Are you currently certified as a Backflow Prevention Assembly Tester by an approved entity such as the American Water Works Association?

    1. Yes (Expiration must be after today)
    2. No (You do not meet the minimum qualifications.
12. 1.a) If you answered yes above, please upload a copy of your current AWWA certificate.*
14. 2.) Do you wish to be listed as available for hire to the general public for testing?

    1. Yes
    2. No
16. If yes, what phone number would you like to be listed?
18. 3.) Please provide the following information relative to the test equipment that is at your disposal for Backflow Prevention Assembly Testing. Please be sure to include the following:
    Manufacturer:
    Model:
    Serial Number:
    Calibration Date:*
20. Please upload a copy of the most recent calibration report.*
22. Please list the owner of the Equipment. Include the following:

    Company:
    Contact Person:
    Mailing Address:*
24. By printing my name, I certify that all the above information is true:*
Leave This Blank:


25. Submit Submit and Print

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