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Click ‘Get Form’ to open the pa revocation document in the editor.
Begin by filling in your name as the Declarant at the top of the form. This identifies you as the individual revoking the Power of Attorney.
Next, indicate the date on which you originally executed the Power of Attorney. This is crucial for establishing a timeline.
In the designated space, write down the name of your attorney-in-fact/agent whom you previously appointed. This clarifies who is affected by this revocation.
Complete the statement confirming that you are revoking your previous Power of Attorney. Ensure that it reflects your intention clearly.
Finally, sign and print your name at the bottom of the form, along with your address. This formalizes your revocation and provides necessary contact information.
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OR REVOCATION OF LICENSE the Board determines to revoke a license or registrant, to: (1) Surrender current enrollment agreements (2) Cease and desist from
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