Food Service Sanitation Manager Certification Program Request Form (Page 2 of 2) in pdf

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Division of Food Drugs and Dairies

Instructions for Completion

A. New Certificate

Within approximately 4-6 weeks from the date of your examination if you have not received your

original computer generated application indicating your passing score you may complete this form

and submit it with the required $35 fee. Complete all sections of the form, including the child support

statement and submit it with a $35 check or money order payable to the Illinois Dept. of Public Health or

“IDPH.” The Illinois Food Service Sanitation Manager Certification certificate is valid for five years

upon receipt of the required fee and application/request form. NOTE: You must notify the Department

of any address changes during your certification period.

B. Certificate Renewal

If your certificate expires within the next three months and you have not received a renewal notice,

complete and submit this form, along with a $35 check or money order payable to the Illinois Department

of Public Health. Be sure to mark ONE box, sign and date the child support certification statement. Your

renewal request and the $35 renewal fee MUST be postmarked no later than 30 days after the current

certificate expiration date. Continuing education/examination requirements MUST be met before the

certificate expires.

C. Replacement Certificate

If you need to replace a lost, stolen or misplaced certificate or if you have changed your name or address,

please complete this form and submit

and you need a new certificate which shows these changes

it with the $10 fee.

The certificate holder is required by law to notify the Department of any

change of address. Legal proof of a name change, such as a copy of a driver’s license, copy of a divorce

decree, copy of a firearm owner’s ID (FOID), copy of a passport or copy of a marriage certificate must

accompany a request for name change.

Notification of Last Name and/or Address Changes – Replacement Certificate Not Needed

If you have changed your name or address, but you do not need a replacement certificate which shows

these changes, please complete and submit this form. There is no fee for changes if you do not need an

updated certificate. You must notify the Department of address changes to ensure that you receive your

renewal application prior to the expiration date. Legal proof of a name change, such as a copy of a

driver’s license, copy of a firearm owner’s ID (FOID), copy of a divorce decree, copy of a passport or

copy of a marriage certificate must accompany a request for name change.

E. Reciprocity

If you have a current City of Chicago Food Service Sanitation Manager Certificate and you wish to

receive an Illinois certificate, please complete and submit this form along with a photocopy of your

Chicago certificate. We must verify that you have a valid Chicago certificate. When we receive this

verification, we will send you an application. Do NOT send any money with this request. You will be

billed. Please allow 6 - 9 weeks for processing. Illinois also recognizes many 15 hour courses that result

in certification. Submit a photocopy of your certificate along with the completed FSSMC Request Form.

We will evaluate it and contact you as necessary.

Food Service Sanitation Manager Certification Program Request Form Page 2