Backflow Certification Backflow Certification/Recertification Registration Date* MM slash DD slash YYYY Choose the Class you wish to attend:*CERT CLASS - February 3-7, 2025RECERT CLASS - February 13, 2025CERT CLASS - May 5-9, 2025RECERT CLASS - May 14, 2025CERT CLASS - August 18-22, 2025RECERT CLASS - August 14, 2025CERT CLASS - November 3-7, 2025RECERT CLASS - November 13, 2025Name as it Appears on License* First Last Exp Date (If Backflow Certified already)*Employer*Address* Home Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Cell/Home Phone*Work Phone*FaxPreferred payment method Pay online w/credit card Mail check Other Total $0.00 CommentsThis field is for validation purposes and should be left unchanged. Δ
