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Exception Request
Exception Type
(Value Required)
Variance
Exemption
Accommodation Request
Required
Classification
(Value Required)
Individual
Required
Request Date
09/24/2023
Name
(Value Required)
Required
Agency
(Value Required)
Required
OMD
(Value Required)
Required
Chief Officer
(Value Required)
Required
Reason
(Value Required)
0
of
4000
Required
Duration
0
of
4000
Individual Completing Request
First Name
(Value Required)
Required
MI
Last Name
(Value Required)
Required
Business Name
Working Title
Email
(Value Required)
Required
Primary Phone
Alternate Phone
Address Line 1
Address Line 2
ZIP
City
State
(Value Required)
As the author of this variance/exemption request, you are attesting to the information to be accurate and complete. If submitting on behalf of an individual, you are also attesting the individual is aware of the submission and has consented to such submission.
Required
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