Continuing Education Reporting Form
If you have a license in any of the states listed below, please complete this form. These states require NGWA to submit your Groundwater Week courses directly to the appropriate state agency. If you do not see your state listed below, you are responsible for submitting your own continuing education hours.
Contractor's Name
*
First Name
Last Name
Contractor's Email
*
example@example.com
State(s) where you are licensed. Check all that apply.
*
Illinois
Indiana
Iowa
New Jersey
New Mexico
Ohio
Texas
Virginia
West Virginia
Wisconsin
NGWA Voluntary Certification Program
Illinois Contractor License Number
*
Indiana Contractor License Number
*
License Type-Indiana
*
D-Driller
P-Pump Installer
There is a hard copy form contractors from Indiana and New Mexico must sign on-site. Please confirm you will stop at the education kiosk to complete this form.
*
Yes
No
Iowa Contractor License Number
*
New Jersey Contractor License Number
*
New Mexico Contractor License Number
*
Ohio Contractor License Number
*
Company-Ohio
*
Texas Contractor License Number
*
Virginia Contractor License Number
*
Your Birthdate (required on the course submission form)-Virginia
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
West Virginia Contractor License Number
*
Wisconsin Contractor License Number
*
Is there anything else you would like NGWA to know?
Submit
Should be Empty: