Fillable Affidavit of Practice Have Practiced (AZ Radiation Regulatory Agency)

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Affidavit of Practice Have Practiced (AZ Radiation Regulatory Agency)

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Affidavit of Practice
Have Practiced
I, ___________________________________ certify under penalty of perjury that since my license # _________ -____________
expired on _________/_________/___________ I have been practicing Cosmetic Laser Procedures in the state of Arizona. My
most recent employer:
Date From:
Date To:
NAME
ADDRESS
CITY, STATE ZIP
PHONE NUMBER
SUPERVISOR
SUPERVISOR’S PHONE NUMBER
I, ____________________________________________________(type or print name), do solemnly swear or affirm that the foregoing information
completed by me, or submitted by or for me, is true, complete and correct to the best of my knowledge. Furthermore, should any part of the
information herein provided prove to be false, it shall be just cause for the revocation of any Certificate issued by the Arizona Radiation Regulatory
Agency
NOTARY PUBLIC
____________________________________ Subscribed and sworn to before me this _____day of____________20_____
SIGNATURE OF APPLICANT
____________________________________ _____________________________________________________________
DATE Notary Public
My commission expires:__________________________________________
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Affidavit of Practice Have Practiced (AZ Radiation Regulatory Agency)

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Completed 20 July 2020

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