Purdue University
Environmental Health and Public Safety

Food Service Registration Application for Purdue University Fort Wayne

Name of Event or Festival you are applying for:

Date(s) of the Event or Festival

Food ESTABLISHMENT Name:

Is this a Food Truck?

Yes
No

Food ESTABLISHMENT Campus:

Food ESTABLISHMENT Email:

Food ESTABLISHMENT Phone:

Food ESTABLISHMENT Address:

Food ESTABLISHMENT City/State/Zip:

Food Establishment REPRESENTATIVE Name:

Food Establishment REPRESENTATIVE Email:

Food Establishment REPRESENTATIVE Phone:

Food Establishment REPRESENTATIVE Address:

Food Establishment REPRESENTATIVE City/State/Zip:

Person Responsible for Food Service Registration:

Purdue University requires either a contract or sponsorship to provide food on campus. Please provide the name and contact information of the person responsible for your interest in applying for food service registration. (for example: your event coordinator)

Authority:
Both Purdue University and the State of Indiana (410 IAC 7-24-107) require food service operations to register with Environmental Health and Safety (EHS). Approved registrations are required to be posted in the operation and clearly visible. Annual registrations are valid for twelve months beginning August 1st and expiring July 31st. Temporary registrations are valid only for the specified time period.

I agree and will post my permit in a visible location.
I do not agree, do not process my application.

CERTIFIED FOOD HANDLER Name:

Date Certified:

Accrediting Organization:

Certification Number:

Fee Schedule for External Vendors Only

Annual Registration:
$150.00 for 1-5 Employees
$300.00 for 6-9 Employees
$450.00 for 10 or More Employees

Temporary Registration:
$25.00 for a 1 Day Event
$50.00 for a 2-14 Day Event

Which Registration are you applying For:

Annual Registration 1-5 Employees $150
Annual Registration 6-9 Employees $300
Annual Registration 10 or more Employees $450
Temporary 1 Day Event $25.00
Temporary 2-14 Day Event $50.00

I understand that this is an application only.
Submitting this form does not guarantee I will be approved to serve/sell food at this event.

Purdue WL EHS will review this application, and after review/verification of certification(s), will issue an invoice including the amount due and the mailing address.

I understand and agree. Please process my application.
I do not wish to continue the application process.

Acknowledgment:
By submitting this form you certify the information is correct and that the food service operation will be maintained in compliance with Purdue University food safety best practices and Indiana Retail Food Establishment Sanitation Requirements (410 IAC 7-24) and all other applicable regulatory requirements. Registrations are non-transferrable and non-refundable.

Please sign below and submit your Food Service Registration.

Sign Here

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