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Petition for Waiver Form

Please review DIAL's rules governing waivers in 4 81 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.

Licensee/Registrant Name

License/Registration No.:

Address Autocomplete

Address or Location

Direct Phone Number for Contact Person

Direct Email Address for Contact Person

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 specific rule(s) you are requesting to be waived (if you do not know the rule, please use the above link to review Iowa Administrative Code):

Describe specifically which requirements you are requesting to be waived

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.

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

Yes

If so, what was the outcome?

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:

Explain why following the rule would pose an undue hardship:

Explain how waiving the rule may impact other people:

Explain how the rule is intended to protect the public health, safety, or welfare:

Explain how the public health, safety, or welfare can still be protected if the rule is waived:

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

Yes

If so, who?

Attach copies of any relevant email correspondence

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

Yes

Attach any relevant documentation to support your answers.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I hereby attest to the accuracy and truthfulness of the information contained herein.

Receipt

You will be provided with a Receipt upon submission.

Petition for Waiver Form

Address Autocomplete

Contact Person for Petition for Waiver

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.

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

Attach copies of any relevant email correspondence

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

Attach any relevant documentation to support your answers.

Sign Here

Receipt