Tennessee Affidavit of Retirement From Practice

STATE OF TENNESSEE
HEALTH RELATED BOARDS
227 FRENCH LANDING, SUITE 300
HERITAGE PLACE METRO CENTER
NASHVILLE, TN 37243-1010
AFFIDAVIT OF RETIREMENT
FROM PRACTICE IN TENNESSEE
PLEASE TYPE OR PRINT ALL INFORMATION IN INK.
I,
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
of
(STREET ADDRESS)
(APT.#)
(City)
SOCIAL SECURITY #
(State)
(Zip)
HOME PHONE #
WHO IS LICENSED TO PRACTICE AS A
(GIVE THE TITLE OR YOUR LICENSE)
IN TENNESSEE UNDER THE LICENSE NUMBER
ISSUED ON
(MONTH) (DAY) (YEAR)
DO SOLEMNLY SWEAR THAT I HAVE RETIRED FROM PRACTICE AS THE PROFESSIONAL LISTED ABOVE IN THE
STATE OF TENNESSEE ON THIS DATE
(MONTH)
,
(DAY)
(YEAR)
SIGNATURE OF LICENSEE
SUBSCRIBED AND SWORN TO BEFORE ME THIS
DAY OF
AT
(CITY)
(STATE)
NOTARY PUBLIC
NOTARY SEAL
MY COMMISSION EXPIRES
PH-3460
(Rev. 03/07)
RDA 1786