Fellowship Route: Affidavit Regarding Number of Years in Practice Form

AFFIDAVIT REGARDING NUMBER OF YEARS IN PRACTICE
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 have been in private practice in the field of Hair Restoration Surgery
since
(insert month)
(insert year)
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 NUMBER OF YEARS IN PRACTICE