Water Certification Course Registration Water Certification Date* Month Day Year Attendee Name* First Last County*Address* Street 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 Phone*FaxEmail* System/Company Member Name*Which date & location will you be attending?*April 7-10, 2025 – Northwest MS Community College – SenatobiaJuly 7-10, 2025 – Hospitality Resort Management Center – BiloxiOctober 20-23, 2025 – Cadence Bank Arena – TupeloI am only attending Water CEU Class.*NoYesFor CEU Classes, please register for the MsRWA Fall Training.I will be attending Water Certification Class A (must have 6 to register to hold the class).*YesNoWhich Water Certification Class will you be attending?*BCDWhich Water Certification TEST will you be taking?*AWhich Water Certification TEST will you be taking?*BCDIs your System/Company a MsRWA Member?*Select your membership type MsRWA System Member – $275 Non-Member – $350 (This includes Individual Membership for 1-ONE Year) If the system you are employed with is a MsRWA all then employees are members Re-Testing Only Water CEU Class – ONLY*Select your membership type MsRWA System Member – $275 Non-Member – $350 (This includes Individual Membership for 1-ONE Year) If the system you are employed with is a MsRWA Member then all the employees of the system are members System/Company MsRWA Member #*If you don’t have your MsRWA Member #, call us at 601-857-2433.Testing Fee: See testing info on Memo from MSDH*Click the link below to download the test registration form. https://msrwa.org/forms/2025/2025WCCExam.pdf Fill out the form and submit via the link below. Yes – Testing Fee $110.00 No Computer-Based Examination Registration Form*Registration will not be complete without: Downloading, filling out, and signing this form. Then you MUST fax to: 601-857-2433 / email: mswra@msrwa.org / Upload Yes, I am Faxing my Exam Reg Form to 601-857-2434. Yes, I am emailing my Exam Reg Form to msrwa@msrwa.org Yes, I am Uploading my Exam Reg Form. FileMax. file size: 64 MB.Water Short Course Manual*Would you like a manual Mailed or You can download a free manual at www.msdh.ms.gov ($45 includes S&H)Yes, MailNo, I will download a PDFHow will you be paying for class?*Paying online.Mailing a check.Bringing check to class.Total $0.00 NameThis field is for validation purposes and should be left unchanged. Δ