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CHICAGO DEPARTMENT OF PUBLIC HEALTH FOOD SERVICE MANAGER

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CHICAGO DEPARTMENT OF PUBLIC HEALTH FOOD SERVICE
MANAGER CERTIFICATE APPLICATION
CHICAGO DEPARTMENT OF PUBLIC HEALTH
FOOD PROTECTION DIVISION
FOOD SERVICE SANITATION MANAGER
PROGRAM
Phone: (773) 602-5490
If you require a receipt please include
a self-addressed & stamped envelope.
MAILING ADDRESS:
Kennedy-King College
Food Service Sanitation Program
6301 South Halsted
W Building
Chicago, IL 60621-3979
****Please Print Clearly or Type*****
First Name:
Last Name:
Date:
Apt#:
State:
Zip Code:
Email:
□ NEW/RECIPROCITY REQUEST - PLEASE PROVIDE THE FOLLOWING REQUIRED PRINTED ITEMS:
□ Completed Training Hours’ Verification Form (Instructor led course must be conducted by approved City of Chicago
Instructor verified with completed hours of training verification form. On-line training course needs training hours’ form
completed by proctor or proof of completion from an approved on-line training course.)
□ Valid National Food Protection Manager Certificate from ANSI accredited Testing Agency*
□ Valid Picture ID (Driver’s license, state ID, passport or other government issued ID)
□ $52.00 Cash or Money Order payable to Kennedy-King College (Checks and Credit Cards are NOT accepted.)
If applying by mail a $52.00 Money Order payable to Kennedy-King College is required.
*Approved testing agencies: ServSafe, Prometric, National Registry for Food Safety Professionals, 360 Training, Above Training/State
Food Safety, The Always Food Safe Company or valid Illinois FSSMC
□ DUPLICATE REQUEST - PLEASE PROVIDE THE FOLLOWING ITEMS:
□ Valid Picture ID (Driver’s license or state ID, passport or other government issued ID)
□ $52.00 Cash or Money Order payable to Kennedy-King College (Checks and Credit Cards are NOT accepted.)
If applying by mail a $52.00 Money Order payable to Kennedy-King College is required.
□ CDPH Certificate # __________________________Exam Date: ______________ Exp. Date: ____________
PLEASE ENSURE THAT YOU PROVIDE ALL REQUESTED ITEMS LISTED ABOVE OR YOUR APPLICATION WILL BE RETURNED AND NOT PROCESSED.
Training Provider:
Instructor/Proctor:
Location of Exam (State):
Type of Training (Check One): Instructor Led Class □ or On-Line □
Applicant Signature:
Office Use Only Receipt Number:
AFTER APPLICATION IS APPROVED BY THE FOOD SERVICE SANITATION STAFF - PAY THE CASHIER AT THE
BUSINESS OFFICE LOCATED ON THE 1
ST
FLOOR. RETURN TO THE FOOD SERVICE SANITATION OFFICE
WITH THE APPLICATION AND RECEIPTS FROM THE CASHIIER .
Original Copy FSSP, Yellow Copy Business Office, Pink Copy Applicant
*****Allow 4 – 6 Weeks for Processing *****
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CHICAGO DEPARTMENT OF PUBLIC HEALTH FOOD SERVICE MANAGER

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Completed 9 September 2021

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