Free Authorization to Accept Personal Service and Receive Registered and Certified Mail-F-62308 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62308 (Rev. 07/08)

STATE OF WISCONSIN
Chapter 50.03(2m), Wis. Stats.

AUTHORIZATION TO ACCEPT PERSONAL SERVICE AND RECEIVE REGISTERED AND CERTIFIED MAIL
Chapter 50.03(2m), Wis. Stats., requires that each licensee or applicant for license shall file with the department the name and address of a person authorized to accept service of any notices or other papers which the department may send by registered or certified mail, with a return receipt requested. The department is required to serve any notice or other paper to the most current address on file. The information collected on this form will be used to comply with Chapter 50.03(2m), Wis. Stats., and will be used for no other purpose. Failure to provide the department with the current name and address of the person authorized to accept service may result in a notice of violation and a forfeiture.



Complete, sign, date, and return this form to:



Division of Quality Assurance Bureau of Technology, Licensing and Education P.O. Box 2969 Madison WI 53701-2969 If you have questions about completing this form, please call 608-266-2966.
License Number

Name - Facility

Address - Facility

DQA Regional Office

A. INFORMATION ON FILE This is the name of the person, currently on file with the Division of Quality Assurance, authorized to accept service. If this information is accurate, please sign and date in the space provided and return this form to the address below.
Name - Licensee's Authorized Person to Accept Service (e.g., Administrator, Director of Nursing, etc.) Title

I verify that the above information is correct.
SIGNATURE - Licensee or Licensee's Representative
Date Signed

B. CORRECTIONS OR CHANGES TO INFORMATION ON FILE If the information on file is not accurate, please indicate changes or corrections, including the correct mailing address. Sign, date, and return this form.
Name - Licensee Title

Mailing Address

SIGNATURE - Licensee

Date Signed

C. ALTERNATE AUTHORIZED PERSON TO ACCEPT SERVICE Indicate the name of an alternate authorized agent in this section of the form.
Name ­ Alternate Authorized Person Title

SIGNATURE ­ Alternate Authorized Person

Date Signed