3, When the petitioner can prove compliance with all the terms of the previously issued order and is seeking to have an order issued reinstating a certificate previously revoked.
Petition for Order of Compliance
Board of Osteopathic Examination's
Council of Certified Professional Midwifery
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: _____________________________
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 I am 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 Council's consultant and administrative staff, in their 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 this the_____day of_____, 20_____.
______________________
Petitioner's Signature
Petition for Order Modification
Board of Osteopathic Examination's
Council of Certified Professional Midwifery
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: ________________________
Telephone Number: ________________________
The petitioner respectfully represents that for the following reasons, as substantiated by the attached documentation, the identified provisions of the attached disciplinary order are impossible for me to comply with:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
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 impossibility is the testimony of any individual, including yourself, you must enclose signed and notarized statements from every individual you intend to rely upon attesting, under oath, to the reasons why compliance is impossible. 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 this the____day of____, 20____.
_______________________________
Petitioner's Signature
Tenn. Comp. R. & Regs. 1050-05-.15
Authority: T.C.A. §§ 4-5-202, 4-5-204, 4-5-217, 4-5-223, 63-1-122, 63-1-134, 63-9-101, 63-29-101 et seq., 63-29107,63-29-114, and 63-29-116.