Dps Employer Status Request Form
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1“EMPLOYER” STATUS REQUESTS
Date: ____________ LIMIT OF TWO FORMS PER DAY TO DPS
Processed by DPS _____________
(No more than 12 names per day)
(date and badge)
TO:
FROM:
Check one box:
Status request only
DPS Applicant
Contact Person:
Telephone #:
Status request and request to update employer
Clearance Card Team
Company Name:
information.
FAX #: 602-223-2047
Mandatory: Provide ARS code(s) that require your
Address (street, city, state, zip):
employees to have a clearance card here:
Phone #: 602-223-2279
FAX #:
ALL INFORMATION IN THIS BOX MANDATORY
_____________________________________
One or more of these three columns must be completed
This column for DPS response ONLY
Mandatory
to process request
L1=Level One Card DR=Driving Restricted Card
Last name, First Name
SSN
Card # / Issue Date
Application #
Status (Refer to box checked)
Valid L1 Card
In process
Invalid
#:
Valid Reg Card
Not in system
Pending Reprint
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
Valid L1 Card
In process
Invalid
#:
Valid Reg Card
Not in system
Pending Reprint
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
Valid L1 Card
In process
Invalid
#:
Valid Reg Card
Not in system
Pending Reprint
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
Valid L1 Card
In process
Invalid
#:
Valid Reg Card
Not in system
Pending Reprint
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
Valid L1 Card
In process
Invalid
#:
Valid Reg Card
Not in system
Pending Reprint
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
Valid L1 Card
In process
Invalid
Valid Reg Card
Not in system
Pending Reprint
#:
App Completed
Valid L1 **
Valid Reg **
Issue Date:
**ADDITIONAL INFO ON CARD. REFER TO CARDHOLDER
CLEARANCE CARD.
G:FormsDPS Employer Status Request
(rec’d from DPS 6/14)
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Parent category: Business