APPENDIX I
NOTICE OF INTENT TO DENY
[DATE]
[NAME] and
ADDRESS of APPLICANT]
Re: Application for [TYPE OF CREDENTIAL]; Notice of Intent to Deny
Dear [APPLICANT]:
PLEASE TAKE NOTICE that the state of Wisconsin [CREDENTIALING AUTHORITY] has reviewed your application for a [TYPE OF CREDENTIAL]. On the basis of the application submitted, the [CREDENTIALING AUTHORITY] intends to deny your application for reasons identified below unless, within 45 calendar days from the date of the mailing of this notice, the [CREDENTIALING AUTHORITY] receives additional information which shows that you meet the requirements for a credential.
[STATEMENT OF REASONS FOR DENIAL]
The legal basis for this decision is:
[SPECIFY THE STATUTE, RULE OR OTHER STANDARD UPON WHICH THE DENIAL WILL BE BASED]
If the [CREDENTIALING AUTHORITY] does not receive additional information within the 45 day period, this notice of intent to deny shall operate as a notice of denial and the 45 day period you have for requesting a hearing shall commence on the date of mailing of this notice of intent to deny.
___________________________________________________
[Designated Representative of Credentialing Authority]
PLEASE NOTE that your have a right to a hearing on the denial of your application if you file a request for hearing in accordance with the provisions of Ch.
SPS 1 of the Wisconsin Administrative Code. If you do not submit additional information in support of your application, you may request a hearing within 45 calendar days after the mailing of this notice. Your request must be submitted in writing to the [CREDENTIALING AUTHORITY] at:
Department of Safety and Professional Services
1400 East Washington Avenue
P.O. Box 8935
Madison, WI 53708-8935
The request must contain your name and address, the type of credential for which you have applied, a specific description of the mistake in fact or law that you assert was made in the denial of your credential, and a concise statement of the essential facts which you intend to prove at the hearing. You will be notified in writing of the [CREDENTIALING AUTHORITY'S] decision. Under s.
SPS 1.08 of the Wisconsin Administrative Code, a request for a hearing is denied if a response to a request for a hearing is not issued with 45 days of its receipt by the [CREDENTIALING AUTHORITY]. Time periods for a petition for review begin to run 45 days after the [CREDENTIALING AUTHORITY] has received a request for a hearing and has not responded.
