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2. Name
3. Anonymous

   1. Submit Anonymously
4. Affiliation with the Food Industry*
   -- Select One --Business OwnerManager or EmployeeContractorConsumer

   Please select one that best applies
5. Date and Time submitted*
   Date and Time submitted

   Date and Time submitted
7. Email
8. Are you interested in serving on a committee to further discuss Health Code changes?*
   -- Select One --YesNo
10. Please provide your input regarding the proposed changes to the local Health Code.*
    Please be as specific as possible. Include section numbers you are referring to in your comments.
12. How would you prefer contact regarding Health Code changes?*

    1. Email
    2. Flyer with Utility Bill
    3. Newspaper
    4. Social Media
    5. Other
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14. 1. Receive an email copy of this form.
15. Email address

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16. Submit

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