QC 108 50204 51061 2225 

Cross Connection Specialist Application Phone 971-673-0418 | Fax 971-673-0694

cross.connection@state.or.us | www.healthoregon.org/specialistcertification

This application is for first time Specialist Certification, or if your certification has lapsed for one year or more. This application must be turned in within 12 months of completing the 4-day Cross Connection Specialist course. Please fill out the application completely and accurately. Missing information or attachments will delay the certification process. Keep a copy of the completed application for your records. PLEASE PRINT CLEARLY 

1. PERSONAL INFORMATION

First Name: Middle Name: Last Name: Social Security # (required):

Have you ever been an Oregon certified Tester or Specialist? No Yes, My old cert # is: Are you an Oregon licensed journeyman plumber or apprentice plumber? Yes No 2. ADDRESS INFORMATION

Work Mailing Address: Home Mailing Address:

Company Name 41- PWS ID#

Address Address

City State Zip City State Zip

County County

3. CONTACT INFO

Work: Cell: Home: Email Address: 4. ATTACHMENTS (REQUIRED) 4-day Cross Connection Specialist course completion certificate High School diploma, GED, or a college degree (yes, you can send transcripts) Proof of one year’s experience working in a water system or plumbing. OpCert #: ___________ (see page 2) 5. FEES & PAYMENT OPTIONS

Certification fees are based on your last name. Please read carefully. Instructions on page 2. A-K If we are currently in an EVEN year, the fee is $97.50, and will expire 12/31 this year.

If we are currently in an ODD year, the fee is $195.00, and will expire 12/31 next year. L-Z If we are currently in an EVEN year, the fee is $195.00, and will expire 12/31 next year.

If we are currently in an ODD year, the fee is $97.50, and will expire 12/31 this year. Select ONE Payment Option: Check: Make your check out to OHA Cashier.

Sign and mail all documents to: OHA Cashier; PO Box 14260; Portland, OR 97293 Credit Card: pay online www.healthoregon.org/specialistcertification. If you have never been certified

enter 0000 for your certification #. Name on Credit Card: _________________________ Date Paid: _________ Sign and send all documents (including payment receipt) by mail, email, or fax. Mail: DWS – Cross Connection; 800 NE Oregon Street, Suite 640, Portland, OR 97293 Email: cross.connection@state.or.us OR Fax: 971-673-0694

6. CERTIFY & SIGN

I certify that all information on this application and on the attached documentation provided is accurate. Printed Name:

Signature: Date:

Office Use Only

Fee: ___________ School: ___________ Experience: ___________ S Class: ___________ Approved: ___________ 

Primary Primary

Revised February 2017

Instructions for Cross Connection SPECIALIST Application

APPLICATION INSTRUCTIONS Personal Info Please provide your first, middle, and last name. Social security numbers are required by law, we cannot process an application without it. If you have previously been certified as a tester or specialist please let us know. If you cannot remember your

certification number put a? mark and we will look it up. Please let us know if you are a licensed journeyman plumber or apprentice plumber.

Address Info Please provide us with at least one mailing address. Mark one address as your primary address, this will be the address all of your mail goes to i.e. renewal notices,

certifications, follow up letters, rule change notices, pipeline newsletters.

Contact Info Please provide us with at least one phone number. We may call you occasionally if we have returned mail, or

questions about your application. Please provide us with your email address, we use this to contact you if we have questions about your

application, and to send you copies of your certification.

Attachments All attachments are required for certification Copy of the certificate of completion or letter you received from your 4-day training course. Copy of your high school diploma, GED, or college diploma. Yes, you can send copies of transcripts. You need to provide proof of having 1 year of experience working for a water system, or in the plumbing field.

You may provide your Distribution or Treatment number on page 1 of the application, or provide a copy of your plumbing license, or a letter from your supervisor stating how long you have worked for the water system or company.

Fees & Payments The two-year certification cycle is split up based on your last name. Last names that begin with A-K expire in even numbered years. Last names that begin with L-Z expire in odd numbered years. Fees are based on where we are in the certification cycle. Fees are prorated by 50% if applications are submitted ½ way through the cycle. A-K - If we are currently in an EVEN year, the fee is $97.50, and will expire 12/31 of this year.

If we are currently in an ODD year, the fee is $195.00, and will expire 12/31 of next year. L-Z - If we are currently in an EVEN year, the fee is $195.00, and will expire in 12/31 of next year.

If we are currently in an ODD year, the fee is $97.50, and will expire 12/31 of this year. Check: Make your check out to OHA Cashier. Sign and mail all documents to: OHA Cashier; PO Box

14260; Portland, OR 97293 Credit Card: pay online www.healthoregon.org/specialistcertification. If you have never been certified or

can’t remember your #, enter 0000 for your certification #. Sign and send all documents (including payment receipt) by mail, email, or fax. Mail: DWS – Cross Connection; 800 NE Oregon St, Suite 640, Portland, OR 97232 OR Email: cross.connection@state.or.us OR Fax: 971-673-0694

RENEWAL Individual renewal forms will be mailed to all current Specialists approximately 90 days before they expire. Renewal forms are not available on-line. The following must be completed to maintain your cross connection specialist certification:

Successful completion of an approved Cross Connection Specialist renewal course or 0.6 CEUs in water related meetings or classes taken within the prior 2-year certification period. (This is not required for your first renewal, but for every renewal after your first)

Renewal fee of $195.00. There is a $50.00 reinstatement fee if your renewal is submitted after January 31st