Operator Response to an Inspection
Use this form to submit a response to a Clark County Indiana Health Department Food Inspection Report (State Form 50047 (2-01))
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business/Organization Information
Business/Organization Name
*
Business/Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Inspection Information
Date of the Inspection
*
-
Month
-
Day
Year
Date
Name of the Inspector
*
Provide your response to the inspection report provided by the Clark Co Health Department in the space below.
*
Additional Comments
Submit
Should be Empty: