ࡱ> CEB[ bjbj *4jj_l 8 , Tr \ \ \ \ \ |t$] }ri0\ \ 00,\ \ a,,,0f\ \ ,0,z,\ f 4VS ,w0,,Hearing Request Form Date: FORMTEXT      Name of Applicant: FORMTEXT      Address of Applicant: FORMTEXT      Phone Number of Applicant: FORMTEXT      Statement of Department Action, Inaction, Ruling or Decision Upon Which Hearing is Requested 1. If hearing is requested for denial of permit, on what date was permit applied for: FORMTEXT      2. The date of inaction, action, ruling or decision by the Department: FORMTEXT      3. Name of the Department officer(s) or employee(s) responsible for action, inaction, ruling or decision by the Department: FORMTEXT       FORMTEXT      4. Brief statement of why applicant disagrees with the Department s action, inaction, ruling or decision: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      5. Nature of the hearing requested: (Please indicate the nature of the hearing requested by checking the appropriate box or boxes below.)  FORMCHECKBOX  Informal hearing  FORMCHECKBOX  Formal hearing  FORMCHECKBOX  Request that formal rules of evidence apply to hearing procedure All costs of a formal hearing, including the cost of a Hearing Examiner and a Court Reporter shall be borne by the nonprevailing party in such hearing, and applicant, by signing this request, does hereby consent to  be liable for such costs if he, or she, does not prevail.6. Signature of applicant: If request is signed by person other than applicant, identify relationship between the person signing and the applicant: FORMTEXT       FORMTEXT      DR Form 378, Mar 82/ FORMTEXT       Attachment  ZZ-2 *68LNPZ\<>RTV`bf &{jDCJOJQJUjCJOJQJU 5OJQJ5CJOJQJj\CJOJQJUjCJOJQJUjtCJOJQJU jCJOJQJUmHnHujCJOJQJUjCJOJQJU CJOJQJ0*6^`<dkkD$$Ifl0@ * \4 laD$$Ifl0@ * \4 la$Ifx df ZpD$$Ifl0X * D 4 la$If h$Ifx$xa$D$$Ifl0@ * \4 la       ( * 0 2 F H J T V \ ^ r t v jCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUj,CJOJQJU jCJOJQJUmHnHujCJOJQJU 5OJQJ CJOJQJjCJOJQJU2zpj$If h$If3$$Ifl4*+4 la $ h$Ifa$D$$Ifl0*$4 la Xj7X3$$Ifl4*+4 laF$$Ifl40h*4)4 la h$IfD$$Ifl0* $4 la   , . 0 X Z \ XiXiXiXF$$Ifl40h*4)4 laF$$Ifl40h*4)4 la h$If  4 6 8 ` b d XXXXXXF$$Ifl40h*4)4 la h$If    " $ & 0 2 8 : N P R \ ^ d f z | ~ βΤΖΈzj:CJOJQJUjCJOJQJUjNCJOJQJUjCJOJQJUjbCJOJQJUjCJOJQJU CJOJQJ jCJOJQJUmHnHujCJOJQJUjvCJOJQJU0    < >  XXXiF$$Ifl40h*4)4 la h$IfF$$Ifl40h*4)4 la     * , . 8 : > D    V Z \ x z ~ zlj CJOJQJUj CJOJQJU56OJQJ6CJOJQJj5CJOJQJU5CJOJQJ 5OJQJj CJOJQJUj& CJOJQJU jCJOJQJUmHnHujCJOJQJUjCJOJQJU CJOJQJ(  V X ln$%`a|̌̌T̸̸t3$$Ifl4*+4 la h$If3$$Ifl4*+4 la lnad{|}~  (*,68<dfz|~߶ߗ{6]jUmHnHujZ U jUj CJOJQJU jCJOJQJUmHnHujn CJOJQJUOJQJ5CJOJQJ 5OJQJ6CJOJQJ CJOJQJjCJOJQJUj CJOJQJU(|}~|3$$Ifl4*+4 laF$$Ifl40@ * \4 la h$If:<Xicac 0*F$$Ifl40h*4)4 la h$IfF$$Ifl40* $4 la(PP&P/ =!"#$%tDText1tDText2tDText3tDText4tDText5tDText6tDText7tDText8tDText9vDText10vDText11vDText12vDText13vDText14vDText15vDText16vDText17vDText18vDText19vDText20vDText21vDText22tDeCheck1tDeCheck2tDeCheck3vDText23vDText24vDText25 i4@4 NormalCJ_HmH sH tH B@B Heading 1$$@&a$5CJOJQJ<A@< Default Paragraph Font,, Header  !, , Footer  !&)@& Page Number4>@"4 Title$a$5CJ$OJQJF"@F Caption(]^5CJOJQJa4/0CWXnfz{GHUijk,-.BCDXYZnop  HI$%`a|}~$%b000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000  d  |  '-COUnzfrxUagkw}$*.:@DPVZflp|  "9EKaFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtG G G FtFtF4Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22Check1Check2Check3Text23Text24Text25DogVl/E[q :b .Vyh~+AWm #Lb.CVnfyUhk~+.ADWZmp  #89L^b.CVnfyUhk~+.ADWZmp &( #89L^b3333 Valued Gateway Customer,D:\backup\AutoRecovery save of Document4.asdValued Gateway Customer*\\DORSRV50\wrdctr\template\other\dr378.dotSusie KalkwarfV:\template\other\dr378.dotdor28023V:\template\DOR Forms\dr378.dotdor28023%V:\Row-man\Attachments\AttachZZ-2.dotdor28023%V:\Row-man\Attachments\AttachZZ-2.dot/0CWXnfz{GHUijk,-.BCDXYZnop  HI$%`a|}~$%b@(-((daPPPP P PP @PUnknownGz Times New Roman5Symbol3& z Arial"h[iF\iF iF @!!0dvHearing Request Formdor28023dor28023Oh+'0  8 D P \hpxHearing Request Form9ear dor28023equor2AttachZZ-2.dot  dor280232.d3r2Microsoft Word 9.0m@F#@XKS@RUS@VS՜.+,0 hp  NDOR  v2 Hearing Request Form Title  !"$%&'()*+,-./013456789;<=>?@ADRoot Entry FɌ4VSFData 1Table#WordDocument*4SummaryInformation(2DocumentSummaryInformation8:CompObjjObjectPoolɌ4VSɌ4VS  FMicrosoft Word Document MSWordDocWord.Document.89q