PPM.5280.634.2018.01 Cross Connection Program

City of Raleigh Public Utilities Cross Connection Program Certification/Recertification School Registration Form

Please indicate for which course you are applying: ☐ Certification ($200.00 for initial Certification) Textbook required for course ☐ Backflow Prevention: Theory and Practice Textbook 2 nd Edition ($75.00) ☐ Re-Certification* ($80.00 for renewal of current certification) ☐ Orientation* ($25 for testers were not certified by COR and desire to test in Raleigh) * Please attach copy of backflow certificate with application. Course Dates: / - / /20___

Office Use Only Certification #: RAL _________ Expiration Date: ____________ Exam Grade: ________ Practical Grade: _______ Payment Received: _____/____/ 20__ Email Confirmation Sent: _____/____/20___

Certification and Recertification Students: Please clearly type your name as you would like for it to appear on your certificate and tester’s card. Name: First MI Last Suffix Home Address:

Street

City

State

Zip Code

Home Phone:

Cell Phone:

Email:

(Email account required. Registration confirmation will be sent by email) Company: Job Title: Company Address:

Street

City

State

Zip Code

Business Phone:

Business Email: Please provide the following information regarding test equipment you will be bringing to the Course. Contact the City of Raleigh if you do not have test equipment.

Brand:

Model#:

Serial #:

All checks or money orders should be made payable to the City of Raleigh and mailed to: City of Raleigh Public Utilities Cross Connection Program PO Box 590 Attn: Candia Perry Raleigh, NC 27602 Refunds minus $25 cancellation fee will be issued for cancellations received in writing 5 business days before the scheduled class. Refund requests can be mailed to address above or emailed to Candia.McKenzie-Perry @raleighnc.gov Please allow 2-3 weeks to process your request. Question regarding registration: Cross Connection 919-996-274 7 or Cross.Connection@raleighnc.gov

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