Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
Complete the entire form and submit supporting documents, including a copy of the Inspection
Report/Safety Order. This request will be denied if more than 90 days have passed since the safety
order was issued.
Individual Completing Form
Duration of extension request: 30 days 60 days
(length must be justified)
Describe in detail the reason for the extension
Copy of inspection report or safety order attached
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.