Change of Information Form

Certified BATs must submit this form to notify Washington Certification Services of changes to their contact information. The Waterworks Operator Certification Program will not consider appeals from a BAT that is assessed a renewal late fee, or that does not renew a certificate or meet the professional growth requirement due to failure to report a change or provide a valid email address. Only a home address will be accepted as the mailing address of record. A business or employer address may not be used.

Required Information

BAT ID # *:

Last Name on Record *:

First Name *:

Home Mailing Address Currently On File with Washington Certification Services *:

City *:

State *:

Zip Code *:

Email :

Information Changes

Home Mailing Address:

City:

State:

Zip Code:

Email:

Phone Number:

Alternate Phone Number:

Name Change

First Name:

Last Name:

I authorize Washington Certification Services to make these changes to my current information. *Authorization Required

Washington Certification Services

Backflow Assembly Tester

Change of Information Form

* Required Verification Information:

Please fill out all that apply.