Form 1a - Application For Id Cards - District Of Columbia Department Of Health Page 3
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3GOVERNMENT OF THE DISTRICT OF COLUMBI A
DEPARTMENT OF HEALTH
HE ALT H REGUL AT ION AND LI CENSING ADMINIS TR ATIO N
Application for ID Cards
TYPEWRITTEN RESPONSES REQUIRED
Please refer to instruction sheet for additional information
(Please Do Not leave any blank fields - use “NONE” or “n/a” if not applicable)
Replacement
Renewal
New
(must select one)
Check Type of Application:
CFPM ($35/$15)
SPO ($10)
MM ($35)
MT ($35)
(must select
one)
First Name
Middle Initial
Last Name
Home/Mailing Address
Floor/Location/Apartment #:
City
State
Zip Code
Email Address
Daytime Telephone
Cell/Evening Telephone
(if applicable)
Establishment Name
DOH Sticker #
Establishment Address
QD
ZipCode Ward
Establishment/Business Phone
Establishment Contact/ Site Supervisor
Test Score, *Cert # or Lic. #:
:
Test Org or Type
:
________
Issue/Exam Date
*only ServSafe applicants can submit certificate number in lieu of score
Credit/Debit Card can ONLY be used in the Processing Center
Payment Amount: $______
Credit
Check
:
#:
Money
/Debit Card#
Order #:
REPORT FRAUD, WASTE, AND ABUSE: To report fraud, waste, or abuse within the District government, contact the DC Office of the
hotline.oig@dc.gov,
Inspector General’s hotline by phone at 1-800-521-1639 (toll free) or 202-724-TIPS (8477), by email at
or by TTY at 711
For additional information, visit the Office of the Inspector General’s website at
oig.dc.gov
I understand that, anyone who makes a false statement on this application can be criminally prosecuted; and, if convicted, fined up
to $1000, imprisoned up to 180 days, or both, under D.C. Official Code § 22-2405.
Please provide the name and contact information of the person authorized to communicate with DOH on your behalf:
Alternative Contact’s Name:
Alternative Contact’s Email:
(area code) Cell Phone:
____________
_______________________ ___________
By signing or entering my name on this form, I attest that all statements are true and accurate.
Date:______
Signature:
FOR OFFICE USE ONLY
Issue Date:______
Rec’d Date:______
Rec’d/Proc’d by:______ ID#: _______ Email Date:_____ ____
P.O. Box 37489 * Washington, D.C. 20013 * Phone (202) 535-2180 * Fax (202) 535-1359
Form 1a
*Required information
–
application will not be processed if missing or incomplete
v8 - Sept 2017
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