Form Center

2. 
3. Gillespie County Health Division | 1906 N. Llano Suite 100 Fredericksburg, TX 78624 | Health@fbgtx.org | 830-990-2027
5. Request for Inspection Application

   Please fill out this application to request an inspection from the Gillespie County Health Division. This is a request form, once received we will be in contact to accept payment and schedule the inspection. 

   Payment methods: Credit Card (fees apply) and Check. 

7. Name of Organization Requesting Inspection*
9. Contact First Name*
10. Last Name*
12. Mailing Address
14. City
15. State
16. Zip
18. Telephone Number at Address*
20. Type of Business to be inspection
    -- Select One --Church Non-profit Food Preparation KitchenISD School Cafeteria Daycare Other
22. If selected other, please explain:
26. Name of Establishment to be Inspected*
28. Physical Address of Establishment to be Inspected*
29. Suite #
31. City
32. State
33. Zip
35. Telephone Number of Establishment to be Inspected*
36. Point of Contact at Establishment*
38. Days of Operations

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday

    1. Thursday
    2. Friday
    3. Saturday
39. Hours of Operation
41. Requested Inspection Month
    -- Select One --January FebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

    Requested does not mean guaranteed scheduled date

43. ESTABLISHMENT INSPECTION FEE -- $100 (FOR EACH INSPECTION)
45. Inspections will be scheduled through the Gillespie County Health Division once full payment is received. Payment methods accepted are Check, Credit Card (fees apply) and cash.
47. VERIFICATION: I SWEAR OR AFFIRM THAT ALL INFORMATION IN THIS APPLICATION IS TRUE AND CORRECT. I FURTHER CERTIFY BY SIGNATURE HEREON, THAT I AM AUTHORIZED TO EXECUTE THIS DOUMENT. I FURTHER CERTIFY THAT I HAVE READ AND UNDERSTAND CHAPTER 437 OF THE HEALTH & SAFETY CODE, THE APLLICABLE PROVISIONS OF 25 TEXAS ADMINISTRATIVE CODE, CHAPTERS 228 & 229, AND AGREE TO ABIDE BY THEM.
49. CONFIRMATION*

    1. Agree
51. First Name*
52. Last Name*
54. Today's Date*
    Today's Date
55. Email Address*
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

* indicates a required field