HTML Preview Apprentice Registration page number 1.
Revised 08/06/2012
OSSF Apprentice Registration Form
Please type or print in ink. For more information, see page 2.
APPRENTICE REGISTRANT
________________________________ __________________________
Name (First, Last) Social Security No.
________________________________ __________________________
Email Address Date of Birth
________________________________ ___________ _____ _______
Mailing Address (or PO Box) City State Zip
________________________________ __________________________
Daytime Phone (home or cell) Work Phone
As the registrant, I certify that all of the information on this form and all of its attachments are true
and correct to the best of my knowledge and belief. I acknowledge that I must operate under the
direct supervision of a licensed Installer.
Signature:
____________________________
Date:
__________________
If you have questions on how to fill out this form or about the On-site Sewage
Facility program, please contact us at 512/239-6133.
Social Security Number (SSN) Statement: The Texas Family Code requires the disclosure of
your SSN for purposes of assisting in the collection of Child Support obligations. In compliance
with the TGSL program, your SSN may also be used to verify eligibility to renew a license.
Mail completed application and $111 registration fee (payable to TCEQ) to:
Texas Commission on Environmental Quality
On-Site Sewage Facility Program, MC 214
PO Box 13088
Austin TX 78711-3088
TCEQ USE ONLY
Received By: Method of Payment: Fee Received Date:
Registration Effective Date: Registration Expiration Date:
TCEQ