2. 

3. CRAVEN COUNTY

   HEALTH DEPARTMENT

   ENVIRONMENTAL HEALTH

4. 2818 Neuse Blvd

   New Bern, NC 28562

   (252) 636-4936

   
   

8. FOOD SAFETY ADVISORY COUNCIL MEMBER APPLICATION

   Food Program Application

    For more information about the Food Safety Advisory Council (FSAC), see our website at cravencountync.gov. Contact Margareta Slagle at (252) 636-4936 if you have any questions or concerns. 

10. APPLICANT INFORMATION

12. Name*
13. Phone Number*
15. Address*
17. City*
18. State*
19. Zip Code*
21. Email Address*

23. MEMBERSHIP CATEGORY (SELECT WHICH CATEGORY APPLIES TO YOU)

25. Owner or manager of a:*

    1. Full-service restaurant
    2. Limited-service restaurant
    3. Fast food restaurant
    4. Temporary event
    5. Catering company
    6. Mobile unit
    7. School
    8. Commissary kitchen
    9. Other
26. Public:*

    1. General public member with an interest in food sanitation, safety, and operation
    2. non-managerial food service employee
    3. Public interest group
    4. Food education
    5. Legislature
    6. Health care professional
    7. Other
28. Name of food establishment*
29. Name of organization (if applicable):
31. Why are you interested in being a member of the FSAC?*

33. CERTIFICATION AND ACKNOWLEDGEMENT

35. By signing this document, I certify that the above information is provided as true and accurate to the best of my knowledge. I understand that:*

    1. I will be expected to attend FSAC meetings regularly.
    2. I will notify the Health Department if my membership category changes.
37. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Electronic Signature*
40. Date*
    Date
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field