Petition for Waiver: Dental Board

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List each rule you are requesting to be waived.

Describe the circumstances that makes it necessary for your to request a waiver.

Explain why applying the rule would result in undue hardship:

Explain why waiving the rule would not prejudice the substantial legals rights of any person:

Indicate whether the requirements of the rule, from which you are seeking a waiver, are also contained in statute or other provision of law:

Explain how will the public's health, safety, and welfare be substantially protected in an equal manner if the rule is waived in your case:

Provide a brief history of any prior contacts between you and the Board regarding the activity or license/registration that would be affected by the waiver

Provide information known to you regarding the Board's action in similar cases

Provide the name, address ,and telephone number of any public agency or political subdivision that also regulates the activity in question, or that may be affected by the petition

Provide the name, address, and telephone number of any person or entity that you are aware of who would be adversely affected by granting this waiver.

Provide the name, address, and telephone number of any person with knowledge of the relevant facts relating to the proposed waiver.

Provide signed releases of information authorizing persons with knowledge regarding the request to furnish the Board with information relevant to the waiver.

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I hereby attest to the accuracy and truthfulness of the above information

Receipt

You will be provided with a Receipt upon submission.