DDW-2024-010422

☐
Proof of Citizenship

Under Utah State Law the Utah Department of Environmental Quality (DEQ) is required to verify the lawful presence
in the United States of an individual at least 18 years of age (includes sole proprietor doing business under assumed
name) who has applied for Water Operator certification or Backflow Technician certification. This law also applies for
renewal, reinstatement, and reciprocity applications. These documents will be confidential and not distributed
publicly.
Applicants for these certifications are required to notarize and attach the following documents:
 Complete and attach the form below
 Attach copy of your government issued photo ID
 Have the document notarized
Questions? Division of Drinking Water 195 North 1950 West P.O. Box 144830 Salt Lake City, UT 84114-4830 Phone: [phone] http://drinkingwater.utah.gov
I’ve already submitted a citizenship form.
U t a h Department of Environmental Q u a li t y
Certification Pursuant to U C A 6 3 G - 12 - 104 This paperwork must be:
 Completed prior to issuance of
certificate.

I, , hereby certify under penalty of perjury that I am:
Full Name
☐ a United States citizen. Must have copy of government issued photo ID attached.
OR
☐ a qualified alien as defined in 8 USC, Sec. 1641, and lawfully present in the United States.
Alien ID #:
Dated this day of , 20 .
Applicant’s Full Name:
Address:
Applicant’s Signature:
SUBSCRIBED AND SWORN to before me this day of , 20 . County: State: . Government Issued
PHOTO ID
(Place copy here)
(driver’s license, passport, etc.) (can attach copy, cut and tape, or print copy on back)
NOTARY PUBLIC
My commission expires: