Name:(Must provide for D.E.P. and Labor & Industry)

Date:

Address:(Must provide for D.E.P. and Labor & Industry)

City:   State:   Zip Code:

Social Security Number:(Must provide for D.E.P. and Labor & Industry)

Phone:               

Supervisor Name:

Supervisor Phone:

Company: Pennsylvania-American Water -------------------------------------------------------------------------------        

District or Location: Select One Abington Bangor Berwick Brownell Brownsville Butler Ceasetown Clarion Coatesville Forest City Frackville Norristown Glen Alsace Hershey Indiana Kane Kittanning Lehman Pike McMurray Milton Mechanicsburg Nazereth New Castle Norristown Penn Water Phillipsburg Pittsburgh Pocono Punxsutawney Royersford Susquehanna Uniontown Valley Warren Wilkes-Barre Wyomissing Yardley Other ----------------------------------------------------------------------------- (Please select one)

Distribution Experience: 0-1 Years 2-4 Years 5-10 Years 11-15 Years 16-25 Years 26 + Years Select One ---------------------------------------------------------------------------

Do you currently have a Class E License? Yes No Select One --------------------------------------

Do you currently have a job in distribution? Select One Yes No ----------------------------------------------

(Only click one time or you will register twice)