Declaration Of Primary State Of Residence

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STATE OF TENNESSEE
DEPARTMENT OF HEALTH
BUREAU OF HEALTH LICENSURE AND REGULATION
OFFICE OF HEALTH RELATED BOARDS
665 MAINSTREAM DRIVE
NASHVILLE, TN 37243
tn.gov/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
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?
In accordance with: the Nurse Practice Act, Tennessee Code, Chapter 63-7 part 301-304 (Nurse
Licensure Compact), I declare the State of _________________ as my primary state of residence and
that such constitutes my permanent and principal home for legal purposes. Please include one of the
forms below to show evidence of primary state of residence:
A driver’s license with a home address
a.
b.
Voter registration card displaying a home address
c.
Federal income tax return declaring the primary state of residence:
d.
Military Form DD2058, State of Legal Residence Certificate, or Military form DFAS 702
Defense Finance and Accounting Service Military Leave and Earning Statement.
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:_____________________
PH-3913
RDA s 836-1
(REV 8/25/16)

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