Fillable AFFIDAVIT OF RETIREMENT FROM PRACTICE IN TENNESSEE STATE (State of Tennessee)

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AFFIDAVIT OF RETIREMENT FROM PRACTICE IN TENNESSEE STATE (State of Tennessee)

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PH-3460 RDA 1786
(Rev. 03/07)
STATE OF TENNESSEE
HEALTH RELATED BOARDS
665 MAINSTREAM DRIVE
NASHVILLE, TN 37243
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) (State) (Zip)
SOCIAL SECURITY # HOME PHONE #
WHO IS LICENSED TO PRACTICE AS A
(GIVE THE TITLE OF 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
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AFFIDAVIT OF RETIREMENT FROM PRACTICE IN TENNESSEE STATE (State of Tennessee)

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Completed 16 September 2021

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