(a) The request shall contain at least: - (i) Name, address, and telephone number of the person requesting the hearing, and on whose behalf the hearing is being requested;
- (ii) The reason for the request, including the nature of the departmental action, order or determination being contested; and
- (iii) Name and address of the requesting party's legal counsel or representative, if the requesting party has retained counsel or a representative at the time the request for hearing is made.