Complete reverse side
CFPM Renewal Application
CERTIFIED FOOD PROTECTION MANAGER (CFPM)
CFPM Certificate # FM Certificate effective date
Certificate expire date
Applicant Information
□
Check box to indicate name change
Name
Last First Full middle name
Mailing address
Street Apt. (if applicable)
City State ZIP Code County
Social Security Number*
*Required under Minnesota Statutes, Section 270C.72, Subdivision 4
Applicant phone
Applicant email
Preferred method to receive renewal notifications
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Mailing address □ Applicant email
Continuing education
Provide documentation of at least four contact hours of approved continuing education
completed between the effective date and expiration date of the Minnesota CFPM certificate.
The continuing education course certificate must include:
1. applicant's name;
2. title of the approved course;
3. number of approved contact hours;
4. course date;
5. instructor's name; and
6. instructor's telephone number or e-mail address.
For Office Use Only:
Date Received:
Amount: $ _
Check #: _
Approved: Yes _ No _
2
C F PM R E N E WA L A PP L IC A T I O N
Submit application and continuing education certificate
Before mailing, be sure to include the following
1. Completed and signed application form. This application must be submitted no more than 6
months following the expiration date of the CFPM certificate.
2. Copy of your continuing education certificate(s).
3. Check or money order made payable to Minnesota Department of Health for $35 – NO
CASH, CREDIT or DEBIT CARDS ACCEPTED.
Minnesota Statute 157.16, Subd. 2a. states, an applicant for certification or renewal certification
must submit a $35 fee. This fee is nonrefundable.
Mail to
Minnesota Department of Health
Certified Food Protection Manager
Food, Pools, and Lodging Services Section
PO Box 64495
St. Paul, MN 55164-0495
Individuals applying for CFPM in the state of Minnesota
The commissioner of health will use information provided in this application to determine if you
meet the requirements for food protection manager certification. Submitting false information is
grounds for denying your application or suspending, revoking or taking other disciplinary action
against your certificate, if issued. Failure to provide required information may delay the
processing of your application and may be grounds for denying your application.
For information on licensing data see Minnesota Statutes, Section 13.41.
Notice: The issuance of a dishonored check to this department will require a service charge of
$30 per check as in Minnesota Statutes, Section 604.113, Subdivision 2(a). Additional civil
penalties may be imposed for nonpayment.
I certify that the information provided and submitted on this application is accurate and
complete.
Signature Date
Resources
Minnesota CFM Renewal (www.health.state.mn.us/divs/eh/food/cfm/howto.html#renewcfm)
ANSI-CFP Accreditation Program (www.ansi.org/accreditation/credentialing/personnel-
certification/food-protection-manager/ALLdirectoryListing?menuID=8&prgID=8&statusID=4)
Minnesota Department of Health
Food, Pools, and Lodging Services Section
651-201-4500
health.fmc@state.mn.us
www.health.state.mn.us
January 2022
To obtain this information in a different format, call: 651-201-4500.
