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U.S. Department of Health and Human Services

Food

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FDA Standardization Nomination Form - Annex 1

FDA Procedures for Standardization of Retail Food Safety Inspection Officers

Table of Contents


TO:                 FDA REGIONAL FOOD AND DRUG DIRECTOR
 
FROM: ________________________________________________________________
 
SUBJECT:    REQUEST FOR FDA STANDARDIZATION
 
DATE:_________________________________________________________________
 
APPLICANT INFORMATION

Candidate's

Name:

Title:

 

Office Telephone Number:

 

Home Telephone Number:

Office Fax Number:


Office Email Address:


Agency:

Office Address:

City:State:Zip:

Home Address:

City:State:Zip:

 

BACKGROUND INFORMATION
Length of Service With Agency:
 
 

 

Present Duties / Date Assigned:
 
 
 

 

Prior Retail Food Safety Experience:Dates:
  
  
  
  

 

Formal Education/ Training Background:
 
 

 

Continuing Education: (List hours of education with course titles/dates, within the last 2 years) Note: 20 contact hours minimum to qualify for nomination.
 
 
 
 

 

Other Prerequisites Completed:
 
 
 
 

SUPERVISOR'S SIGNATURE (Confirming request for nomination):

NAME (Print):_________________________________

NAME (Signature):______________________________ Date:_____________

TITLE:________________________________________