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Form ph 4183-2026

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The document is a declaration form required by the Tennessee Department of Health for applicants seeking initial licensure or reinstatement. It mandates verification of citizenship status under the 'SAVE Act,' requiring applicants to confirm whether they are U.S. citizens, qualified aliens, or nonimmigrants. The form outlines necessary documentation for each category and includes penalties for false claims regarding citizenship.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your healthcare profession in the designated field. Ensure that you print legibly for clarity.
Fill in your name, including last, first, middle, and maiden names as applicable. This information is crucial for identification.
Provide your mailing address accurately to ensure proper communication regarding your application.
Indicate whether you are a United States citizen by checking the appropriate box. If you are a foreign national not physically present in the U.S., select 'Yes' and ensure to sign in front of a notary.
If claiming U.S. citizenship, check 'Yes' and provide one of the acceptable forms of identification listed on the form.
For those who answered 'No' to question 4, circle the category that applies to you from the provided options.
Finally, affirm the truthfulness of your statements by signing and dating the form before a notary public.

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ph 4183

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