Petition for Order of Compliance
Board of Social Worker Licensure
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 Board'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
Tenn. Comp. R. & Regs. 1365-01-.11
Authority: T.C.A. §§ 4-5-202, 4-5-204, 63-1-134, 63-23-101, 63-23-102, 63-23-104, 63-23-105, 63-23106, 63-23-108, and 63-23-110 and Chapter 1016 of the Public Acts of 2008, § 1.