Retail Food Safety Advisory Council

Retail Food Safety Advisory Council - Application Form

DFRS-BFRB-081
Wis. Stat. § 15.04(1)(c)

Completion of this form is required to apply for the Retail Food Safety Advisory Council. Failure to complete the form may result in denial of your application. Upon appointment to the Council, your name, organization, and photograph (optional) will be displayed under the members section on the Council’s webpage.

Personally identifiable information you provide may be used for purposes other than that for which it was collected. Wis. Stat. § 15.04(1)(m). This information will be available for public review upon request, pursuant to Wisconsin's Public Records Law, Wis. Stat. §§ 19.31 to 19.37.
I would like the opportunity to serve on the Retail Food Safety Advisory Council (Council).*

Yes
Candidate Name*

First NameLast Name
Candidate Affiliation (business or association to which you are affiliated)*
Candidate Title*
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
What category best describes your affiliation?*

Wisconsin Restaurant Association representativeTavern League of Wisconsin representativeWisconsin Grocers Association representativeWisconsin Fuel & Retail Association representativeRetail food establishment serving meals industry member (large food facility or chain)Retail food establishment not serving meals, such as grocery store (large)Convenience store industry member with significant food serviceLocal regulatory officials: Representing Wisconsin Association of Local Health Departments and Boards (WALHDAB)Wisconsin Technical College System or Universities of Wisconsin representing the culinary programs in WisconsinAn at-large memberWisconsin Hotel & Lodging Association representativeWisconsin Association of Meat Processors representativeWisconsin Bakers Association representativeRetail food establishment serving meals industry member (small food facility less than 50 units/locations)Retail food establishment not serving meals, such as grocery store (small)Meat establishment industry member with a retail food service operationWisconsin Department of Public Instruction (DPI) Schools and Institutions Representative
What retail food safety or regulatory experience, and/or education, would you bring to the Council?*
What interpersonal, organizational, and/or leadership skills would you bring to the Council? Please list any current or previous participation on other councils/committees/boards.*
In what capacity/role could you share information and communicate with the constituency you represent?*
Would you be able to attend quarterly meetings and contribute time to other RFSAC subcommittees/activities?*

YesNo
Other areas of interest (tell us about yourself):*
Applications are reviewed and submitted to the Secretary of the Wisconsin Department of Agriculture, Trade and Consumer Protection for consideration.
Should be Empty:

Retail Food Safety Advisory Council - Application Form