"Employer Status Request Form" - Arizona

Employer Status Request Form is a legal document that was released by the Arizona Department of Health Services - a government authority operating within Arizona.

Form Details:

  • Released on June 1, 2014;
  • The latest edition currently provided by the Arizona Department of Health Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arizona Department of Health Services.

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Download "Employer Status Request Form" - Arizona

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“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:\Forms\DPS Employer Status Request
(rec’d from DPS 6/14)
“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:\Forms\DPS Employer Status Request
(rec’d from DPS 6/14)