(Revised 5/1/19 ML 3549)
View Archives
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 Department.
A copy of this form must be sent to the Aging Services Division.
Copies of this form can be obtained at http://www.nd.gov/eforms/.
