Experience Route: Affidavit Regarding Clear & Unrestricted Licensure Form

AFFIDAVIT REGARDING CLEAR AND UNRESTRICTED LICENSURE
Complete as appropriate:
STATE OF
COUNTY OF
COUNTRY OF
Affiant (applicant)
(insert applicant name)
upon oath, duly sworn hereby certify to the American Board of Hair Restoration Surgery that I hold a clear and unrestricted license in the following state(s) and/or country(s):
If applicable, please list any countries outside of the US that you hold licensure in.
Affiant states no more:

Affiant (applicant) Signature
Witness certifies this affidavit was signed by the above named applicant:
Witness Signature
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

AFFIDAVIT REGARDING CLEAR AND UNRESTRICTED LICENSURE