NeRWA Training Registration

Nebraska Rural Water
Western Conference Registration

To pre-register for the Western Conference complete the following form.
* indicates required information

*Name
*System

*Address
Your Job title is:

*City
Operator

*State Board Member

*Zip Code Sales Rep or Factory Rep

*Telephone
Backflow Tester or Plumber

E-mail

*Choose the days you will attend *Please Indicate certificates held and Numbers.

Water Operator Yes No Lic #

Backflow Yes No Lic #

Wastewater Yes No Lic #

Onsite Wastewater Yes No Lic #

Well Drillers Yes No Lic #

Size of System You Are Representing Less than 3,300 Population

Between 3,300 and 10,000 Population

Over 10,000 Population

If you have questions or comments, please provide them in the area provided, thank you.

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