Change of Information Form

Certified waterworks operators must submit this form to notify Department of Health and Washington Certification Services of changes to their contact information. Only a home address will be accepted as the mailing address of record. The Waterworks Operator Certification Program will not consider an appeal from an operator that is assessed a renewal late fee, does not renew a certificate, or does not meet the professional growth requirement due to failure to provide a valid home and email address.

Required Verification Information

Waterworks Certification Number*

Last Name*

First Name *

I certify that I am the operator identified above and I authorize Department of Health and Washington Certification Services to make these changes to my contact information. I understand that third parties, such as employers, are prohibited from submitting changes. *Authorization Required

Change Operator Information

Home Mailing Address

City

State Zip Code

County

Personal Email

Work Email

Home Phone Number

Mobile Phone Number

First Name

Last Name

Change Employer Information

New Employer

WFI ID#

Employer Mailing Address

City

State Zip Code

Employer Phone Number:

Washington Certification Services

Waterworks Operators

Change of Information Form

Enter only the information that has changed.

Name Change