Fillable BREATH ALCOHOL CERTIFIED OPERATORS CHANGE OF STATUS (AGENCY/NAME) (Kansas Department of Health and Environment)

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BREATH ALCOHOL CERTIFIED OPERATORS CHANGE OF STATUS (AGENCY/NAME) (Kansas Department of Health and Environment)

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U.S.A. forms for Kansas Department of Health and Environment

BROWSE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KS) FORMS

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Health & Environmental Laboratories
Breath Alcohol Program
6810 SE Dwight Street
Topeka, KS 66620
Phone: 785-296-1642
Fax: 785-559-5206
www.kdhe.ks.gov
BREATH ALCOHOL CERTIFIED OPERATORS
CHANGE OF STATUS (AGENCY/NAME)
OPERATOR NAME: ______________________________________ OPERATOR #: __________
NAME ON CURRENT CERTIFICATION: _____________________________________________
(IF NAME CHANGE IS OCCURRING)
AGENCY CHANGE
CURRENT AGENCY NAME: __________________________________ AGENCY # B- _________
NEW AGENCY NAME: ______________________________________ AGENCY # B- _________
(IF APPLICABLE)
EFFECTIVE DELETION DATE (CURRENT AGENCY): ______/______/______
(Last day of employment)
EFFECTIVE TRANSFER DATE (TO NEW AGENCY): ______/______/_______
(First day of employment)
NAME CHANGE
EFFECTIVE DATE FOR NAME CHANGE: _____/_____/_____
____________________________________
AGENCY CUSTODIAN SIGNATURE
Please, fax completed forms to Denae C. Jones at 785-559-5206 or e-mail to Denae.c.jones@ks.gov. Thanks.
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BREATH ALCOHOL CERTIFIED OPERATORS CHANGE OF STATUS (AGENCYNAME) (Kansas Department of Health and Environment)

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Completed 20 July 2020

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