Provisional License Agreement (Sample Form or SFN 1020 pdf format) 660-05-65-65

(Revised 5/1/19 ML 3549)

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A provisional license shall be issued only to an applicant who has in writing waived:

1. The right to a written statement of changes as to the reasons for the denial of an unrestricted license; and
2. Waived the right to an administrative hearing, in the manner provided in the North Dakota Century Code chapter 28-32, concerning non-issuance of an unrestricted license.

Any provisional license issued shall be accompanied by a written statement of the violations signed by the Aging Services Division or their designee and, in writing acknowledged by the applicant/provider.

Copies of the provisional license must be sent to the County Social Service Agency.

SFN 1020 pdf format is available through Aging Services Division.