Application for Certification

Application for Certification

North Carolina Onsite Wastewater Contractor Inspector Certification Board
The “Certification” will apply to all persons who wish to become certified as an On-Site Wastewater System Installer or as an On-Site Wastewater System Inspector as defined by Chapter 90A Article 5 of the General Statutes of NorthCarolina.

“Contractor” means a person who constructs, installs, or repairs, or offers to construct, install,or repair an on-site wastewater system in the State
“Person” means all persons, including individuals, firms,partnerships, associations, public or private institutions, municipalities, or political subdivisions, governmental agencies,or public or private corporations organized and existing under the laws of this State or any other state or country
“Inspector” means a person who conducts an inspection in accordance with rules adopted by the Board.
“Inspection”means an examination of an on-site wastewater system permitted under the provisions of Article 11 o Chapter 130A of the General Statutes, when requested by a lending institution, realtor, prospective homebuyer, or other impacted party as acondition of sale, refinancing, or transfer of title, which examination shall meet the minimum requirements established bythe Board.
Personal Information
First Name*
Middle Name (If Applicable)
Last Name*
Social Security Number*
Check If Applicable

Active MilitaryVeteran
Date of Birth*

MonthDayYear
Date
Home Mailing Address
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Company Information

If you do not have a company, please enter your personal information again.
Company Name*
If you do not have a company name, enter your name
Company Address*

Street Address

Street Address Line 2

CityState

Zip Code
County *
Company Telephone*
This number will appear on the NCOWCICB Website
Grade Level Descriptions
Grade II: Single Septic tank, Conventional (Gravel) Gravity System
Multiple tanks, Grease traps, Single Pump or Single Siphon, Fill Systems, Sand LinedTrench, and any approved gravity or single pump dispersal system not specified inGrade Level III or Grade Level IV

Grade IV: Grade II plus: Dual Pumps or Dual Siphons, Systems of greater than 1500 gpd to less than 3000 gpd,Low Pressure Dispersal, Flow Equalization, and any system requiring ground waterlowering device with a pump. Systems equal to or greater than 3000 gpd, Multiple Off-Site Systems, IndustrialProcess Wastewater, Residential Wastewater Treatment Systems (RWTS), TS-I andTS-II System, Drip Dispersal Systems, and Wastewater Reuse Systems or anyPretreatment Component.
Please check all that apply:*

Application for Grade II $200Application for Grade IV $300Application for Inspector $200
Total Fee Amount Due and Enclosed with Application
Disclosures
1. During the past three years, have any judgments, liens, lawsuits, or claims been entered or filed against the certification holder or responsible persons (including partners, officers, major shareholders, and management level employees) in the company listed on the application?*

YesNo
2. Are there any liens for labor or materials filed on any of your projects?*

YesNo
3. Have you or any responsible managing employee of the sole proprietorship, member of the partnership, or officers of the corporation listed on the application been convicted of a felony offense in the past three years?*

YesNo
If you answered yes to questions 1, 2, or 3 above, please briefly describe:
Brief explanation of the situation disclosed in application related to judgements, liens, lawsuits, claims, liens, or felony convictions: This explanation is required in order for you application to be processed by the NCOWCICB.
Have you been investigated for employee misclassification in the last twelve months?*

YesNo
I understand that the following are required for a complete application:*

Completed application for certification with no blanksCertification fee (check or money order only)Copies of required attendance certificatesExam application if applying for Grade Level IV and/or InspectorThe above must be mailed to the NCOWCICB at P.O. Box 132 Lawsonville NC 27022Exam applications must be postmarked a minimum of 15 business days prior to the exam date. Current exam application form is available at www.ncowcicb.info under forms.I understand that I am not certified until I have received a certification in the mail from the certification board.I understand that incomplete application packages will be returned by the board.
I am aware that only the certification holder, company owner(s) or W2 employees may work under the certification held. Furthermore, by my signature below I hereby affirm that no one other than those stated here shall be allowed to install or inspect using this certification. I affirm the information contained in this application is true to the best of my knowledge and hereby agree upon certification to abide by the laws and rules of the state governing on-site wastewater construction, installation, repair, and/or inspection.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Application for Certification

Personal Information

Home Mailing Address

Company Information

Grade Level Descriptions

Disclosures