Osah Form 1 (Georgia Department Of Public Health)

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OSAH FORM 1
This form is available online at
or by telephone request at (404) 657-2800.
OSAH USE ONLY
AGENCY
CASE TYPE
DOCKET NUMBER
COUNTY
JUDGE
DOCKET NUMBER:
DPH
GEORGIA DEPARTMENT OF PUBLIC HEALTH
Non-Agency Party County of Residence:
Date Request for Hearing Filed
Agency Case Number:
with Agency:
Check Here if an Application Was Denied:
Check Only One in This Box:
ASL (Ambulatory Service License)
FSEP (Food Service Establishment Permit, If Issued by PH)
BCW (Babies Can't Wait)
MFR (Medical First Response Service License)
CT (Cardiac Technician License)
NT (Neonatal Transport Service License)
EMS (Emergency Medical Service)
PI (Paramedic Instructor License)
EMT (Emergency Medical Technician License)
SSM (Sewage Management)
EMTI (Emergency Medical Technician Instructor License)
WICV (WIC Vendor)
CONTACT PERSON IN AGENCY
NAME
TEL NO
FAX NO
CURRENT ADDRESS INCLUDING ZIP CODE ON HEARING REQUEST
POSITION
EMAIL
NON-AGENCY PARTY
NAME
TEL NO
FAX NO
EMAIL
CURRENT ADDRESS INCLUDING ZIP CODE
TEL NO
FAX NO
ATTORNEY
PERSONAL REPRESENTATIVE NAME (IF APPLICABLE)
EMAIL
ADDRESS INCLUDING ZIP CODE
GEORGIA BAR NO
AGENCY PARTY
NAME AND TITLE OF CONTACT IN OFFICE
DIRECT TEL NO
FAX NO
CURRENT ADDRESS INCLUDING ZIP CODE
EMAIL
ATTORNEY NAME (IF APPLICABLE)
TEL NO
FAX NO
EMAIL
ADDRESS INCLUDING ZIP CODE
GEORGIA BAR NO
Revised 8/3/11

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