Free Application For Certified Food Manager, F-47346 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-47346 (Rev. 07/08)

STATE OF WISCONSIN Bureau of Environmental and Occupational Health Chapter 254, Subchapter VII, Wis. Stats.

APPLICATION FOR CERTIFIED FOOD MANAGER
Type or Print Following Information. Provision of Social Security Number is required under Chapter 250.041 (1)(f), Wisconsin Statutes and will be used only for that purpose. Drivers License Number is optional and will only be used as a unique identifier. Application may be returned or delayed if Social Security Number is not provided. Last Name First Name Middle Initial

Social Security Number

Drivers License Number (Optional)

Permanent Street Address

City

State

Zip Code

County

Daytime Telephone Number ( )

SIGNATURE ­ Applicant

Date Signed

Enclose a photocopy of a certificate, form or letter, verifying a passing score from the testing agency. Originals will not be returned. Remit check for $10.00 payable to: Department of Health Services Division of Public Health Food Safety and Recreational Licensing P. O. Box 2659 Madison, Wisconsin 53701-2659

For Office Use Only ID Number Test Taken Date Taken