Grade Level Change Modification Form

Grade Level Change Modification Form

North Carolina Onsite Wastewater Contractor Certification Board
Applicant Name*

First NameLast Name
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState

Zip Code
Office Phone Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Are you currently certified by the NCOWCICB?*

I currently hold certificationI do not hold certification, but I have submitted an application
I currently hold the following certification(s):

Grade Level IGrade Level IIGrade Level IIIGrade Level IVInsepctor
Grade Level I Certification Number*
Grade Level II Certification Number*
Grade Level III Certification Number*
Grade Level IV Certification Number*
Inspector Certification Number*
I have submit application for the following:

Grade Level IIGrade Level IVInspector
Change of Grade Level*

I wish to upgrade/modify my application to the following and have enclosed the appropriate fee payable to NCOWCICB. Note: Appropriate class hours must be acquired and a passing exam if required.
I wish to upgrade/modify my application to the following:*

Grade Level II upgrading to Grade Level IV -- $100Grade Level II adding Inspector -- $200Grade Level III adding Inspector -- $200Grade Level III upgrading to Grade Level IV -- $50Grade Level IV adding Inspector - $200Inspector adding Grade Level II Installer -- $200Inspector adding Grade Level IV Installer -- $300
If you have questions realated to how you should modify your certification, contact the state certification board at 336-202-3126 - csstephens@ncowcicb.info
Provide additional information to the certification board if needed:
Not Required
DATE*

MonthDayYear
Date
APPLICANT SIGNATURE*

Clear
Should be Empty: