TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER m: FOOD, DRUGS AND COSMETICS
PART 750 FOOD SERVICE SANITATION CODE
SECTION 750.APPENDIX D PERMISSION TO RETAKE CERTIFICATION EXAMINATION FORM

Section 750.APPENDIX D   Permission to Retake Certification Examination Form

 

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

 

OFFICE OF HEALTH PROTECTION

 

Request for Permission to Retake

Food Service Manager Certification Examination

 

 

 

Name:

 

 

(Last)

(First)

(Middle Initial)

Address:

 

 

 

Telephone:

 

Social Security #:

 

 

Course

 

School:

 

Instructor:

 

Date of Course:

 

thru

 

Dates of previous exams:  First

 

Second

 

 

Affidavit:       I certify that this student has completed my approved Food Service Manager's Certification course.

 

 

Signature:

 

 

(Instructor)

 

2609K

 

(Source:  Added at 13 Ill. Reg. 18888, effective December 1, 1989)