(Revised 1/1/08 ML 3118)
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The purpose of this form is for the provider to request an appeal in the event of a license denial or revocation.
It is the responsibility of the provider to complete this form with the assistance of the County Social Service Agency or the Human Service Center.
A copy of this form must be sent to the Division.
Copies of this form can be obtained at http://www.nd.gov/eforms/.
