ServSafe Enrollment Form
Please complete this form. The registration fee of $125 (check or money order (ONLY) made payable to Robeson County Cooperative Extension) is due by May 23. Payments can be mailed to Denese Prevatte, P. O. Box 2280, Lumberton, NC 28359.

For questions, contact Janice Fields, Extension Family and Consumer Sciences Agent, at 910-671-3276 or by E-mail at

Email address
Today's Date
Name (First, Last)
Your answer
Home Mailing Address (Address, City, State, Zip)
Your answer
Phone Number (Indicate home and cell)
Your answer
E-mail Address
Your answer
Food Service Establishment (Place of business)
Your answer
Business Mailing Address (Address, City, State, Zip)
Your answer
Business Phone Number
Your answer
Do you plan to attend the review session?
Where would you like your test score sent?
Have you taken ServSafe before?
Large-print exam needed?
North Carolina State University and North Carolina A&T State University commit themselves to positive action to secure equal opportunity regardless of race, color, creed, national origin, religion, sex, age, veteran status, or disability. In addition, the two universities welcome all persons without regard to sexual orientation
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