STATE OF TENNESSEE DEPARTMENT OF HEALTH BUREAU OF …
STATE OF TENNESSEE
DEPARTMENT OF HEALTH BUREAU OF HEALTH LICENSURE AND REGULATION
OFFICE OF HEALTH RELATED BOARDS 665 MAINSTREAM DRIVE NASHVILLE, TN 37243 health
615-532-5166 or 800-778-4123 Fax 615 741-7899
DECLARATION OF PRIMARY STATE OF RESIDENCE
NAME: _________________________________________________SS#:__________________
ADDRESS: ___________________________________________________________________________________
_____________________________________________________________________________________
City
State Zip Code
Home/Cell Telephone Number
Email: ________________________________________________________________________
RN/LPN TN license #________________________DATE OF BIRTH:_____________________
___YES ___NO
Are you currently active duty military? If YES, provide Leave and Earning Statement (LES)
___YES ___NO Are you currently a federal government employee?
I declare that my current primary state of residence is _________________. This state is referred to as my home state under the Nurse Licensure Compact and means that it is my "declared fixed, permanent, and principal home for legal purposes."
I intend to practice in the state(s) of: ________________________________________________
_____________________________________________________________________________
I affirm that this completed form and any submitted materials contain no willful misrepresentation and that the information is true and complete to the best of my knowledge.
Sign here to affirm:______________________________________Date:_____________________
ALLOW 4-6 WEEKS FOR YOUR FILE TO BE REVIEWED
PH-3913 (REV 8/25/16)
RDA s 836-1
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- us department of treasury bureau of fiscal
- state of tennessee department of education
- us department of treasury bureau of fis
- tennessee department of health license renewal
- state of tennessee department of licensure
- state of tennessee dept of education
- tennessee department of health license verification
- tennessee department of health nurse license
- tennessee department of health and licensure
- department of labor bureau of statistics
- tennessee department of health licensure
- tennessee department of health license renew