Free 48137.pdf - Indiana

LOCAL BOARD OF HEALTH MEMBERSHIP ROSTER
State Form 48137 (R5 / 2-09) INDIANA STATE DEPARTMENT OF HEALTH

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INSTRUCTIONS:

Mail to:

Indiana State Dept of Health Primary Care Office ­ 2J 2 N. Meridian St Indianapolis, IN 46204

__________________________________________ (county or city health department)

Due Date: January 31
TERM OF OFFICE Begin End
(MM/DD/YY) (MM/DD/YY)

NAME

PROFESSION

E-MAIL ADDRESS

APPOINTING BODY County City (X) (X)

POLITICAL PARTY AFFILIATION Dem Rep Other (X) (X) (X)

Board Chairperson: ________________________________________________ Person Completing Form: ___________________________________________

Vice-Chairperson: ___________________________________________________ Phone Number: (_______)______________________ Date: ________________