Maryland Plumbing-Heating-Cooling Contractors, Inc. 10176 Baltimore National Pike, Suite 205 Ellicott City, MD 21042-3652 (410) 461-5977 fax (410) 750-2507 e-mail: phccmd@aol.com www.phccmd.org Registration Fees: $ 175. Maryland PHCC Member ~ $ 275. Non-Member
BACKFLOW RE-CERTIFICATION COURSE – APPLICATION
ACCEPTED & APPROVED FOR CERTIFICATION IN THE STATE OF MARYLAND, W.S.S.C. & THE COMMONWEALTH OF VIRGINIA
January 11, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD January 25, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD February 8, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD February 22, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD March 14, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD March 28, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD April 4, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD April 25, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD May 9, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD May 30, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD June 13, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD June 27, 2020 – Dundalk Community Colleg January 11, 2020 - Thos. Somerville Co. July 11, 2020 - Thos. Somerville Co. – 1510 Tilco Drive – Frederick, MD July 25, 2020 – Dundalk Community College – 7200 Sollers Point Road – Dundalk, MD
_____________________________________________________________________________ A passing grade commensurate with National requirements on the final written examination and a satisfactory completion of the “Hands on” performance test will result in Certification. NOTE: Class schedules are updated approximately every 30 days. To reserve your space please be sure to register early. Class size is limited and applicants are accepted on a first-come first-serve basis. No recording devices allowed in the classroom. Name ___________________________________________________Home Phone (
) ______________________
Address_______________________________________________ Last 4 Digits of Social Security # _____________ City______________________________________________State__________Zip Code________________________ Certification expiration date:______________________ School Attended: _____________________
e-mail address:___________________Plumbing License held 0 Baltimore County 0 State 0 WSSC Please check box(s) that apply
Company Name__________________________________ (
) ________________ e-mail: ____________________
Class Location request___________________________________ Class date requested _______________________
Enclosed is my check made payable to Maryland PHCC in the amount of $__________. Signature of Applicant_____________________________________________________Date____________________
Credit Card # _____________________________ Expiration Date:__________ Security Code_________ Name as it appears on Credit Card_________________________________________________________ Billing address for credit card_____________________________________________________________ Street City State Zip Code AUTHORIZED SIGNATURE OF CARDHOLDER:__________________________________________ PAYMENT: Payment must accompany the completed application. Please make check payable to Maryland PHCC and mail to: Maryland PHCC, Suite 205, 10176 Baltimore National Pike, Ellicott City, MD 21042. Enclosed is my check in the amount of $_______ CANCELLATION: What if I need to cancel? Applicants who cancel up to 10 days prior to the start of the course will forfeit 25% of the Total fee to cover administrative fees. CANCELLATIONS LESS THAN SEVEN (7) BUSINESS DAYS PRIOR TO THE START OF CLASS WILL FORFEIT ALL FEES.