Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 38 - BOARD OF HOMEOPATHIC AND INTEGRATED MEDICINE EXAMINERS › Article 1 - GENERAL › Section R4-38-108 - Application for Licensure

Current through Register Vol. 30, No. 28, July 12, 2024
A. To
				apply for licensure, an applicant shall submit the following directly to the
				Board:
1. An application form that contains
				the following information about the applicant:
a. Name as the applicant wants the name to
				appear on a license;
b. Social
				Security number, as required under A.R.S. §§
											25-320(P)
				 and
				25-502(K);
c. Date and place of birth;
d. Personal identifying characteristics
				including gender, weight, height, eye and hair colors, and any identifying
				marks;
e. Business name and
				address;
f. Residential
				address;
g. Business telephone and
				fax numbers;
h. E-mail
				address;
i. Date on which the
				applicant expects to take the written examination required under A.R.S. §
											32-2913;
j. Name of the approved medical school from
				which the applicant obtained an allopathic or osteopathic medical degree and
				the date of the degree;
k. Name of
				the hospital program at which the applicant served as an intern and the years
				of the internship;
l. Names and
				addresses of three physicians who will send the Board letters of recommendation
				for the applicant;
m. List of the
				states or other jurisdictions in which the applicant is or ever has been
				licensed to practice medicine;
n.
				List of specialty colleges of which the applicant is a member;
o. List of specialty boards by which the
				applicant is certified;
p. List of
				the places where the applicant has practiced medicine and the dates of
				practice;
q. Statement indicating
				whether the applicant:
i. Has, within the last
				10 years, had a medical malpractice judgment entered against an applicant or
				settled a malpractice claim against the applicant;
ii. Has ever been convicted of or pled guilty
				or nolo contendere to a criminal charge in an adult court of record;
iii. Has been charged with a crime that is
				pending adjudication in an adult court of record;
iv. Has had a state or other jurisdiction
				refuse or deny the applicant a license to practice medicine or has allowed the
				applicant to withdraw a license application instead of being refused or denied
				a license to practice medicine;
v.
				Has had a state or other jurisdiction take disciplinary action against the
				applicant's license to practice medicine including placing the license on
				probation, suspending the license, limiting or restricting the license,
				revoking the license, or accepting surrender of the license;
vi. Has had a state or other jurisdiction,
				including a federal agency, suspend, limit, restrict, revoke, deny, or accept
				surrender in lieu of action of the applicant's registration to possess,
				dispense, or prescribe controlled substances;
vii. Has or had, within the last 10 years, a
				mental illness or psychological condition that impaired the applicant's ability
				to practice medicine or function as a medical student;
viii. Is now or has been within the last 10
				years dependent upon alcohol or drugs; and
ix. Has had a specialty board or college
				suspend, revoke, or deny certification to the applicant.
r. Notarized signature and attestation that
				the information provided is true, correct, and complete;