*Once the request is received, our office will send a notice to you. Please be sure to list your current mailing address below. Please attach any significant documentation that corresponds with your appeal request. You may contact our office if you have questions about the documentation that may be needed. The Appeal Request Form and its accompanying documents must be received by our office no later than 10 days prior to the Board Meeting.
Email:
Date:
Full Name:
Address:
City:
State:
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Zip:
License Number (if applicable):
Request Details: (please write in detail the reason for the request):
If you would prefer to file your appeal by mail, download and print this form.
