ENVIRONMENTAL COMPLAINTS AND LOCAL SERVICES

CERTIFIED SOIL PROFILER APPLICATION

Registration and payment for all certification classes must be completed 7 days prior to attendance.

Please complete all the information requested.

1. GENERAL INFORMATION
First Name:	M.I.:	Last Name:
Prefer to go by:
Home Address:
City:	State:	Zip:	County:
Contact Number:	( ) -	Email Address:
2. PROFESSIONAL LICENSING COMPLIANCE REVIEW
RPES/RPS Number:	RLS Reg. Number:
PE Reg. Number:	Soil Scientist:	(number of credit hours)
3. BUSINESS INFORMATION
Please complete this section even if this information is the same as the General Information.
Do you want your business/contact information listed on ODEQ website?	Yes	No
Business Name:
Mailing Address:
City:	State:	Zip:
Business Phone:	( ) -
4. ATTACHMENTS
$25,000 Bond or Affidavit (Tribal or Govt. only)	DEQ Form 002-028 Affidavit Regarding Citizenship
Transcript if applying as a Soil Scientist	Copy of Government Issued Photo ID
Statement of Understanding:
I hereby certify under penalty of law that this application and any attachments contain no willful or negligent misrepresentation or falsification, and that all information is true, accurate and complete. I understand that any misrepresentation or falsification may result in rejection of my application or revocation of any certificate issued as a result of this application.
Signature of Applicant	Date
ODEQ USE ONLY
Account Number	POC Number	Soil Profile Number	Date Received by ECLS