Universal License Recognition Application (ULR)

Have you ever held a license and/or certificate issued by the Virginia Department of Professional and Occupational Regulation?*

YesNo

Name*

First NameMiddle NameLast Name

Maidden or Former Name

Not required

Mailing Address*

Street Address (P.O. Box OK for mailing)

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address*

Street Address (No P.O. Boxes)

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number*

Date of Birth*

Primary Telephone*

Format: (000) 000-0000.

Alternate Telephone

Format: (000) 000-0000.

E-mail Address*

example@example.com

NC Certification Number*

NCOWCICB Certification Number Required PRIOR to submitting application to VA DPOR

Have you ever been subject to a disciplinary action taken by any (including Virginia) local, state or national regulatory body?*

NoYes

If yes, complete the Disciplinary Action Reporting Form.

Have you ever been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the United States of any felony? Any plea of nolo contendere shall be considered a conviction.*

YesNo

If yes, complete the Criminal Conviction Report

Have you been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the United States of any misdemeanor within the last three years (except marijuana convictions)? Any plea of nolo contendere shall be considered a conviction.*

YesNo

If yes, complete the Criminal Conviction Report

By signing this application, I certify the following statements:

I am aware that submitting false information or omitting pertinent or material information in connection with this application will delay processing and may lead to license revocation or denial of license.
I will notify the Board of any changes to the information provided in this application prior to receiving the requested license, certification, or registration including, but not limited to any disciplinary action or conviction of a felony or misdemeanor (in any jurisdiction).
I authorize the Department to verify information concerning me or any statement in this application from any person, or any source the department may contact. I also agree to present any credentials or documents required or requested by the Department.
I authorize any federal, state or local government agency, current or former employer, or other individual or business to release information which may be required for a background investigation.
I have read, understand and complied with all the laws of Virginia related to this profession under the provisions of Title 54.1, Chapter 40, of the Code of Virginia and the Onsite Sewage System Professionals Licensing Regulations of the Virginia Board for Waterworks and Wastewater Works Operators and Onsite Sewage System Professionals.

Acknowledgements*

I understand this does not complete the process. I will need to print the PDF of this application I have been e-mailed and mail it to the address on the form.I will include a $100.00 check or money order made payable to Treasurer of Virginia in the package I am mailing.I will include a verification of license from the NCOWCICB and recognize that a copy of my certification will not be adequate. The verification of license can be requested using the Septic School App. Look for Verifification of License for Virginia. The NCOWCICB will e-mail you a letter to include with the application.I cannot complete this form until I have received a license from NC.If you answered YES to the criminal conviction or disciplinary action questions, the associated forms must be completed and included with this application.

Signature*

Date*

Date