Operator Response to an Inspection

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 NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Business/Organization Information
Business/Organization Name*
Business/Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Inspection Information
Date of the Inspection*

MonthDayYear
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
Should be Empty:

Contact Information