Request for Fee Waiver Application Form

Request to receive Initial Fee Waiver Application Form

NOTE: Giving us your address, phone number, and/or email address is optional. Please note that your information, including your voluntary contact information, questions, or comments, becomes public record subject to public disclosure under the Arkansas Freedom of Information Act. DEQ privacy policy

* Asterisk indicates item is mandatory; all others are optional

To receive a reply to your request, include phone number or e-mail address.

How do you want to receive Fee Waiver Application Form * (Select one)
- Email as an attachment
- Mail to address below
- Prefer to pick up at the front desk of the Arkansas Department of Energy & Environment headquarters
  
  Arkansas Energy & Environment
  5301 Northshore Drive
  North Little Rock, AR 72118

Your Information

*Name:

Phone:

Email Address:

Street Address:

City:

State:

Zip:

Questions / Comments

* I would like to offer the following Questions/Comments:

Internal use only:

NOTE: Please click "Submit" only ONCE.

Request to receive Initial Fee Waiver Application Form

How do you want to receive Fee Waiver Application Form * (Select one)

Your Information

Questions / Comments