Petition for Order of Compliance
Board of Chiropractic Examiners
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
Petition for Order Modification
Board of Chiropractic Examiners
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. 0260-03-.14
Authority: T.C.A. §§ 63-1-122, 63-1-132, 63-1-134, 63-4-106, 63-4-114, 63-4-115, 63-4-119, and 63-4-123.