653—3.17 (17A,147,148,150,150A) Sample petition for waiver. A petition for waiver filed in accordance with this chapter must meet the requirements specified herein and must substantially conform to the following form:

BEFORE THE BOARD OF MEDICINE	
Petition by (name of petitioner)
for the waiver/variance of (insert rule citation)
relating to (insert the subject matter).	}	PETITION FOR
WAIVER/VARIANCE	
	  1. 	 Provide the name, address, and telephone number of the petitioner (person asking for a waiver or variance). Also, the name, address, and telephone number of the petitioner’s legal representative, if applicable, and a statement indicating the person to whom communications concerning the petition should be directed.
	  2. 	 Describe and cite the specific rule from which a waiver is requested.
	  3. 	 Describe the specific waiver requested, including the precise scope and time period for which the waiver will extend.
	  4. 	 Explain the relevant facts and reasons that the petitioner believes justify a waiver. Include in your answer all of the following:a. Why applying the rule would result in undue hardship to the petitioner;
b. Why waiving the rule would not prejudice the substantial legal rights of any person;
c. Whether the provisions of the rule subject to the waiver are specifically mandated by statute or another provision of law; and
d. How substantially equal protection of public health, safety, and welfare will be afforded by a means other than that prescribed in the particular rule for which the waiver is requested.
	  5. 	 Provide a history of any prior contacts between the board and petitioner relating to the regulated activity or license that would be affected by the waiver. Include a description of each affected license held by the petitioner, any formal charges filed, any notices of violation, any contested case hearings held, or any investigations related to the regulated activity, license, registration, certification, or permit.
	  6. 	 Provide information known to the petitioner regarding the board’s action in similar cases.
	  7. 	 Provide the name, address, and telephone number of any public agency or political subdivision that also regulates the activity in question, or that might be affected by the grant of the petition.
	  8. 	 Provide the name, address, and telephone number of any person or entity that would be adversely affected by the grant of the waiver or variance.
	  9. 	 Provide the name, address, and telephone number of any person with knowledge of the relevant facts relating to the proposed waiver.
	  10. 	 Provide signed releases of information authorizing persons with knowledge regarding the request to furnish the board with information relevant to the waiver.
I hereby attest to the accuracy and truthfulness of the above information.

Petitioner’s signature	 	Date