Online Application

Applicant Information ( * indicates required information)
*Name:
*Date of Birth:
(please use the DD/MM/YYYY date format)
*Street Address:
Address2:
*City:
State:
Zip Code:
County:
Phone:
Email:
Gender:
Female Male
Occupation/Affiliation:
Program Interest
Do you own or work at a business associated with private water systems (i.e., well drilling, water treatment, etc.)? Yes No

If yes, please describe the business:
Do you own a private water system (well, spring, or cistern) and depend on it for the water supply to your primary home, vacation home, or camp? Yes No
Briefly explain why you are interested in becoming a Master Well Owner:
Are you willing and able to attend a 1 day training workshop held on a Saturday within your extension region? Yes No
Are you willing and able to fulfill the requirements of educating 100 people (through fairs, public meetings, articles for the newspaper, etc.) about private water system management over the course of two years? Yes No
Are you willing to have your name publicized on our website if you become a certified Master Well Owner? Yes No
Have you had any formal or informal education about water? Yes No

If yes, please describe:

Notification will be sent to the individual described above within 1 month of submitting the application.

 


College of Agricultural Sciences | Forest Resources | Cooperative Extension