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2. Course Title and Date*
   -- Select One --Orientation: September 16, 2022Orientation: November 18, 2022

   Select the Course and Date for which you are registering.

   
   

   Note: Certification and Re-certification courses start at 8 a.m. Orientation courses start at 1:30 p.m.

4. First Name*
   Enter name as you would like for it to appear on your certificate.
5. Middle Name
6. Last Name*
8. Durham Assigned Tester Number (if applicable)
10. Company
11. Job Title
13. Home Address
15. City
16. State
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
17. Zip Code
19. Company/Business Address
21. City
22. State
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
23. Zip Code
25. Phone Number 1*
26. Phone 1 Type
    -- Select One --PrimaryBusinessHomeMobile
28. Phone Number 2
29. Phone 2 Type
    -- Select One --PrimaryBusinessHomeMobile
31. Phone Number 3
32. Phone 3 Type
    -- Select One --PrimaryBusinessHomeMobile
34. Email Address 1*
35. Email 1 Type
    -- Select One --PrimaryBusinessPersonal
37. Email Address 2
38. Email 2 Type
    -- Select One --PrimaryBusinessPersonal
42. NC Conctractor Type
    -- Select One --Fire SprinklerPlumbingMechanicalUtilityNot Applicable
43. NC Contractor Number
45. Test Gage Brand
46. Test Gage Model
47. Test Gage Serial Number
48. Test Gage Expiration Date
    Test Gage Expiration Date
50. Attach Test Gage Calibration form (PDF)*
52. Attach Contractor License Detail (PDF)*
54. Attach Most Recent Tester Course Certificate (Re-certification and Orientation only)
58. By submitting this online application to become or remain eligible to be on the City of Durham's Certified Testers List, the tester (participant) acknowledges and understands that:*

    • It is the tester’s responsibility to provide the update Cross Connection Control Office current and up-to-date information. Anytime the information provide with this application changes the tester must report the changes to the cross Connection Control Office as soon as possible and within 10 business day of the change.
    • Being placed on this list is a privilege, not a right. Therefore a tester or company may be removed from this list and/or disallowed to test in the Durham jurisdiction for reasons including, but not limited to unethical practices, improper conduct, failure to perform testers’ duties, etc.
    • Intentionally Submitting false information on this electronic application, as an attachment, or on test and maintenance reports is a violation of the Federal Safe Drinking Water Act, NC Rules Governing Public Water Supplies, and City of Durham Code of Ordinances. Submitting false information on this electronic application, as an attachment, or on test and maintenance reports may subject the submitter to disciplinary action, fees, fines, and prosecution.
    • I will receive emailed instructions regarding course fee payment via PAYMENTUS and that I am not a registered participant for the course until payment is made and I have received a receipt for the payment. (Once you click the “Submit” button on your application, you may proceed to https://ipn2.paymentus.com/rotp/dhcc and select the appropriate class you have enrolled in and then enter the students name under “Student ID.”)
    • I hereby certify by this submission that the above submitted information and attachments are correct as submitted to the City of Durham’s Cross Connection Control Office for admission to the Certification, Re-Certification or Orientation course.

    1. I certify that I have read, understand, and acknowledge each statement above.
60. Employment certification*

    1. I certify that I am employed by the company listed above as defined by 21 NCAC 50 .0512.
62. I would like to be added to the Certified Testers List upon successful completion of the course.

    1. Yes
    2. No
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field