Free APPENDIX A - Tennessee

*The Form Must Be Original & Completed In Pen*
FORM I-9

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation 220 French Landing Drive Nashville, Tennessee 37243-1002

NOTICE OF WITHDRAWAL OF EXEMPT EMPLOYERS' VOLUNTARY ELECTION
Notice is hereby given that __________________________________________________________
Business Name __________________________________________________________________________________________ Business Address FEIN# __________________________________________________________________________________________ City State Zip

wish to withdraw its voluntary election to come under the provisions of the Tennessee Workers' Compensation Act.
_______________________________________________ Print and Sign Name _______________________________________________ Business Address _______________________________________________ Business Address

Signed this __________________day of_________________________, 20________.

LB-0289 (REV. 12/07)

RDA 10183