Dawson
County
Department
of Environmental Health
207 West Bell Phone (406) 377-5772
Glendive, MT 59330 Fax (406) 377-2022
dsnow@midrivers.com www.dawsoncountymontana.org
Request for Licensing
Exemption for
Non-Profit Organization
Temporary Food Service
This form must be completed and returned to the Dawson County Sanitarian’s Office for approval at least two weeks prior to your proposed food service event or function.
Organization Name
Contact Person(s)
Address Phone
Event Location
Date(s)
I certify that the above named organization is non-profit and tax-exempt under 26 U.S.C. 501 or registered with the Montana Secretary of State as non-profit.
Signature Date
Proposed Preparation Site(s)
Approved by Date
Sanitarian’s Signature