Replacement Certifications Requests

I acknowledge that I will be charged a $25.00 replacement fee for a replacement certificate.

I will pick up the certificate from PHCC.

*

I acknowledge the Fee

Required

Attendee First & Last Name *

Enter the name of the class you need a replacement cert. *

If a Backflow Class please enter your tester number. The Tester Number must be entered. If you don't know please contact the City of Wichita Cross Connection office. *

Name of Company or Person responsible for payment *

Phone # of Person responsible for payment *

Email of Person responsible for payment *