Free 48135.pdf - Indiana

RECORD OF APPOINTMENT OF LOCAL HEALTH OFFICER
State Form 48135 (R4 / 2-09) INDIANA STATE DEPARTMENT OF HEALTH

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INSTRUCTIONS:

Mail to:

Primary Care Office Indiana State Department of Health 2 N. Meridian Street ­ 2J Indianapolis, IN 46204

In accordance with IC 16-20-2-16, IC 16-20-3-9, or IC 16-22-8-30, the Board of Health of ________________________________ has, this the ________ day of _______________________, _______ appointed (name or county or city) (day) (month) (year) ___________________________________ to serve as Health Officer of _____________________________ for a term (name of appointee) (county/city) of four years beginning ________________ ______ ________ and expiring on ______________ ______ _______ (month) (day) (year) (month) (day) (year) ______________________________________________ (signature of Chr. Local Health Board) New Appointment ______________________________________ (date signed) Reappointment

QUALIFICATIONS OF APPOINTEE Indiana License Number: ________________________________ License Unlimited YES NO

Specialty Board Certifications: ________________________________________________________________ Public Health Experience YES NO Location of Public Health Experience: ___________________________________________________________

_______________________________________________________________________________________
Degree: M.D. D.O. Public Health Degree: _______________________________________________ Name & Address of University granting Degree: ________________________________________________________ ___________________________________________________________________Year Granted: ________ Home Address: _______________________________ _______________________________ Office Address: _______________________________ _______________________________ Email Address: _______________________________ Home Phone: (_____)_________________________

Office Phone:

(_____)_________________________

Cell Phone:

(_____)_________________________

Has a State or Territory revoked or suspended a full-practice license held by you within the past five years? YES NO If yes, please describe reason, ______________________________________________________ ________________________________________________________________________________________________ To the best of my knowledge, all of the aforementioned is correct: _________________________________________________________ (Signature of appointed local health officer) ____________________________ (date)

This is to Certify the action of the Local Board of Health in the appointment of the Health Officer of

____________________________________________________
(county/city)

____________________________________________________
(signature county/city executive)

_________________________
(date signed)