Tennessee Affidavit of Retirement From Practice
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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