Petition for Order of Compliance
Temporary Healthcare Staffing Registry
Petitioner's Name:____________________________________
Petitioner's Mailing Address:____________________________
Petitioner's E-Mail Address:_____________________________
Telephone Number:___________________________________
Attorney for Petitioner:_________________________________
Attorney's Mailing Address:______________________________
Attorney's E-Mail Address:_______________________________
Attorney's Telephone Number:____________________________
The petitioner respectfully represents, as substantiated by the attached documentation, that all provisions of the attached disciplinary order have been complied with and is respectfully requesting: (circle one)
Note - You must enclose all documents necessary to prove your request including a copy of the original order. If any of the proof you are relying upon to show compliance is the testimony of any individual, including yourself, you must enclose signed statements from every individual you intend to rely upon attesting, under oath, to the compliance. The Commission's staff, in its discretion, may require such signed statements to be notarized. No documentation or testimony other than that submitted will be considered in making an initial determination on, or a final order in response to, this petition.
Respectfully submitted the ______ day of __________________, 20_____________.
________________________
By: _____________________
Name of Individual Signing on behalf of petitioner
Tenn. Comp. R. & Regs. 0720-46-.07
Authority: T.C.A. §§ 68-11-207, 68-11-213, and 68-11-2206.