10.2014 Toll-Free Telephone: 800-439-8550 Fax: 802-863-7483
Deputy Town Health Officer
Recommendation Form
This is a:
□
New Appointment
□
Re-appointment
Is a resignation letter needed from previous Health Officer?
□
Yes
□
No
Start Date: __________________ Town/Municipality: _________________________
County:____________________ Full Name: _______________________________
Home Delivery Address: ________________________________________________
(DO
NOT
USE
the
Town
Clerk
Office
or
a
Business
for
your
Home
Address)
Street Address for UPS Deliveries: ________________________________________
Email Address:________________________________________________________
Telephone(s): W: ______________ H:________________ Cell: _________________
Education: High School ____ College ____ Other (list) __________________________
Professional Degree: (e.g. MD, RN, DVM, DDS) Occupation: ________________
Please give a brief statement noting why the select board believes the recommended
individual will make a good Health Officer:
Signed:_________________________________ _________________________
Chair of the Local Board of Health Board Meeting Date
Print Name: __________________________________________________________
Return completed recommendation form
to:
VT Department of Health / Environmental Health
108 Cherry Street • PO Box 70
Burlington, VT
05402
Beginning Date: __________________
Expiration Date: __________________
Resignation Date: ________________
Entered: ________________________
