Form Ccc Li 102A – Fill Out and Use This PDF

	Landscape Irrigator Exam - Registration Form
		Infrastructure Training & Safety Institute
		800-SAFE-811 (800-723-3811) ● itsi@teexmail.tamu.edu ● www.teex.org/li
		Mail to: TEEX-ITSI, 301 Tarrow, College Station, TX 77840-7896
I am registering for (check one):		If RETESTING for Landscape Irrigator:	Date exam was failed:________________
Landscape Irrigator Test		Principles of Installation	Location:__________________________
Landscape Irrigator Retest		Principles of Backflow
		Principles of Hydraulics	# of times taken:____________________
		Landscape Irrigation Design
		The $111 license fee is valid for one year from date of first exam. You may retake the exam 3 times within that year if
		necessary; however, you must pay $100 per exam. If you do not pass after 4 attempts or within 12-months from initial
		exam, you must pay the $111 license fee again plus $100 exam fee, submit a new application and retake the exam.

_____________________________________________________________________

Participant Name: (Last, First MI)Social Security Number:

_____________________________________________________________________

Company/Agency:Email Address:

_____________________________________________________________________

Address:

_____________________________________________________________________

City:State:ZIP Code:

_____________________________________________________________________

Business Phone:Home Phone:Fax:

_________________________________	__________________________________
Facility and Date Requested for Exam:	Alternate Facility and Date Requested for Exam:

Registration Information

To register, please complete and return the required documents listed on page two of this packet to The Texas Engineering Extension Service. Be sure to include your TEEX exam fee, your TCEQ license fee and a copy of any applicable course certificates. Please see page two of this packet for additional details. Please do not fold or staple these documents.

The TEEX Customer Care Center must receive all registration documents and payment 14 days prior to the exam date. (No exceptions. Seating is limited.) Note: Registrations are taken into class dates on a first received, first entered basis.

Payment Information – Payment must accompany registration. Make check, cashier’s check or money order payable to Texas Engineering Extension Service (TEEX). The $211 fee for the Landscape Irrigator exam includes a $100 TEEX Exam fee and a $111 TCEQ licensing fee. Irrigator re-tests are subject to a $100 testing fee.

Arrange payment by one of the following methods:

1.

Certified Check* Enclosed payable to TEEX. (No personal or company checks.)

Amount: $__________________

2. Money Order #_______________________

3. Credit Card

Individuals who submit incomplete application packets or inaccurate application information may be subject to processing

delays that prevent attending the requested exam date and location.

*By sending your check, please be aware that you are authorizing the Texas Engineering Extension Service (TEEX) to make a one-time electronic debit from your account at the financial institution on your check. This electronic debit will be for the amount of the check; no additional amount will be added to the amount and ALL transactions will remain secure. Please contact TEEX’s Financial Services Department at 979-458-6906 to learn about other payment options if you prefer NOT to have your check used in this way. We value your business and appreciate your selecting TEEX for your training needs.

CCC-LI-102A

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Revised 1/10/2011