Get Rehs California Form

State of California Health and Human Services Agency California Department of Public Health REGISTERED ENVIRONMENTAL HEALTH SPECIALIST - Continuing Education Verification Form INSTRUCTIONS Complete section below to verify completion of 24 contact hours of Registered Environmental Health Specialist REHS continuing education. If necessary continue on a separate sheet of paper. Send this completed form along with your renewal application and payment to EHS Registration Program MS 7404 PO Box 997377 Sacramento California 95899-7377 Date of Course Contact Hours Received Course Title Name REHS Recognized Provider/ Instructor Accreditation Agency Location TOTAL HOURS I certify that I have taken the courses listed above and will have certificates in my possession to verify successful completion of the continuing education courses listed. I understand that I am responsible for maintaining these legal documents for five years. DO NOT SEND ORIGINAL CERTIFICATES OR COPIES UNLESS INSTRUCTED BY THIS OFFICE* Copies of your certificates will be required to document course completion by the Environmental Health Specialist EHS Registration Program during the audit process. If you are selected for an audit you will be notified by email* You must sign the signature line at the bottom of this form to certify the authenticity of your reported continuing education courses. Signature FOR EHS REGISTRATION PROGRAM USE ONLY REHS 02 6/12 REHS CE Hours Complete Need Further Review Selected for Random Audit. DO NOT SEND ORIGINAL CERTIFICATES OR COPIES UNLESS INSTRUCTED BY THIS OFFICE* Copies of your certificates will be required to document course completion by the Environmental Health Specialist EHS Registration Program during the audit process. If you are selected for an audit you will be notified by email* You must sign the signature line at the bottom of this form to certify the authenticity of your reported continuing education courses.