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Yes No

Requests must be submitted 4 weeks prior to the date of your event.

First Name *

Pools above 2,000 Sqft must have a certified pool director

ZIP *

Lab 2 Address

Lab 2 Phone

Pool Square Footage *

Certified Pool Operator

Name

Phone # At Pool *

Provide details of at least one (1) certified pool operator

Lab 2 Name

Name *

- Scheduled Hours of Operation
- CPO Certificates for Pool Operators
- Certificate for Pool Director
- Lifeguard Certification
- Checklist for Public Recreational Bathing Facilities - Click Here

Applicant Signature *

License Fee

Email Address *

Phone *

Phone

Lab 3 Phone

Phone *

Certified Lab Information

Address *

Lab 1 Address *

Certification

Email

Provide details of at least one (1) designated adult supervisor

Lab 3 Address

Start Date *

Name

Name *

Organization Applying for License *

Certified Pool Director

Lab 3 Name

Name

Phone # *

Last Name *

Phone

Email *

Provide details of at least one (1) lab who will be taking weekly water samples

Designated Adult Supervisor

Lab 1 Phone *

Applicant Information

Phone

End Date *

Pool Location Address *

Required Attachments

Activity Information

I submitted all the required attachments including the 'Public Swimming Facility Checklist'

Lab 1 Name *

Fee

State *

City *