Virginia Center for Very Small Waterworks

REIMBURSEMENT PROCEDURES

Virginia Center for Very Small Waterworks

www.vaclassix.com

Registration Form

VDH Office of Drinking Water

Expenditure Reimbursement Grant

Please complete and submit this entire form along with mailing or faxing a copy of your license to:

Renata Fonville

Training and Development Coordinator

Office of Drinking Water

109 Governor Street, Room 622

Richmond, Virginia 23219

Phone: 804-864-7516

Fax: 804-864-7521 (Attention: Renata)

Middle Initial

Suffix (Jr, Sr, IV)

*First Name

*Last Name

*Address Line 1

Address Line 2

*City

*State

*Zipcode

* Phone # (include area code)

Email address (sample@sample.com)

(*) denotes that the field is required

If you have any questions or comments about the reimbursement procedures, please call Renata Fonville at 804-864-7516 or email her (Renata.Fonville@vdh.virginia.gov)

List the Public Water System Identification Number (PWSID #), Waterworks Name, and License Number for each facility where you are licensed (submit multiple forms if needed)

PWSID#Waterworks NameLicense #

* I am applying for reimbursement for a :

*Total Amount Paid

*Social Security Number (This is used for processing only)