Agencies
|
Governor
Licensure, Compliance & Regulations
Exception Request
Breadcrumb
Save
Doc Hidden
Exception Request
Exception Type
(Value Required)
Variance
Exemption
Special Event
Classification
(Value Required)
Individual
Request Date
09/16/2019
Name
(Value Required)
Popup List of Values: Name
Agency
(Value Required)
OMD
(Value Required)
Chief Officer
(Value Required)
Reason
(Value Required)
0
of
4000
Duration
0
of
4000
Individual Completing Request
First Name
(Value Required)
MI
Last Name
(Value Required)
Business Name
Working Title
Email
(Value Required)
Primary Phone
Alternate Phone
Address Line 1
Address Line 2
ZIP
Popup List of Values: 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.
Old Note
New Note
Save Notes