Form Apo-11 - Petition For A Contested Case Hearing Page 2
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2C. SUBJECT MATTER
17. Board Action Being Contested
18. Board Action Date
19. Item No.
20. Nature and Extent of Petitioner’s Interest That May Be Affected by the Board Action
21. Any Disagreement Petitioner May Have with an Application before the Board
22. Any Relief Petitioner Seeks or Deems Itself Entitled to
23. How Petitioner’s Participation in the Proceeding Would Serve the Public Interest
24. Any Other Information That May Assist the Board in Determining Whether Petitioner Meets
the Criteria to Be a Party under Section 13-1-31, HAR
Check this box if Petitioner is submitting supporting documents with this form.
Check this box if Petitioner will submit additional supporting documents after filing this form.
Petitioner or Representative (Print Name)
Signature
Date
FORM APO-11
Page 2 of 2
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