Organization Name (if any):

Applicant Name:

Mailing Address of Applicant:

City: State: Zip:

Phone Number:

Fax:

Email:

Applicant Certified By:

None

Lincoln County Temporary Food Safety Certificate # (located on back of card)

ServSafe #

Other

Date of Event: Time of Event:

Location:

List food being served:

The applicant attests to the accuracy of the information provided in this application. The Applicant affirms that he/she will comply with the requirements of the Lincoln County Food Service Sanitation Regulations as established by the Ordinance dated 3-23-1998. The Applicant agrees to allow the Regulatory Authority access to the establishment as specified under § 3-203.12 and 5-205.13 and Subparagraph 8-201.14(D)(6) and any other information required by law.