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Department of Inspections, Appeals, and Licensing

amanda.woltz@dia.iowa.gov

6200 Park Ave., Ste. 100 Des Moines, IA 50321

515.281.5944

Petition for Waiver Form

Please review DIAL's rules governing waivers in 481 IAC Chapter 6 prior to filing a petition for waiver.  The deadline for inclusion on the Board's agenda is three weeks prior to a Board meeting.  You must be a licensee/registrant or an applicant who has submitted the appropriate application and fee for the Board to consider a petition for waiver. 

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    Contact Person for Petition for Waiver

    List each rule you are requesting to be waived (you must include the exact rule(s) or subrule(s) from 481 IAC Chapters 550 through 557 or other applicable rules from 481 IAC:

    List the time period for which you are seeking a waiver. The start date must be a future date. An end date must be requested.

    Start Date

    End Date

    Have you previously requested a waiver of any of the rules listed above?

    If a prior petition for waiver was granted or denied, attach a copy of the Board's prior written ruling or correspondence.

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    For each rule you are requesting to be waived, provide the following explanations:

    Have you spoken to a Board compliance officer or other member of Board staff about your request?

    Attach copies of any relevant email correspondence

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    Do you wish to participate in the Board meeting when this Petition will be considered?

    Attach any relevant documentation to support your answers.

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    Sign Here

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    Receipt

    You will be provided with a Receipt upon submission.