Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 08 - ACUPUNCTURE BOARD OF EXAMINERS › Article 3 - AURICULAR ACUPUNCTURE CERTIFICATION › Section R4-8-301 - Application for Auricular Acupuncture Certificate

Current through Register Vol. 30, No. 28, July 12, 2024
To be certified as an auricular acupuncturist to provide
				  auricular acupuncture services in a Board-approved alcoholism, substance abuse,
				  or chemical dependency program, an applicant shall submit an application packet
				  to the Board that includes:
1. An
				application, on a form provided by the Board, that provides the following
				information about the applicant:
a.
				Name;
b. Other names by which the
				applicant has been known;
c. Date
				of birth;
d. Social Security
				number;
e. Home, business, and
				e-mail addresses;
f. Home,
				business, and mobile telephone numbers;
g. A statement of whether the applicant has
				ever been permitted by law to practice auricular acupuncture in another state,
				territory, or district of the United States, or another country or subdivision
				of another country, and if so:
i. A list of
				the jurisdictions in which the applicant has been permitted by law to practice
				auricular acupuncture;
ii. The
				number of each license or certificate;
iii. The date each license or certificate was
				issued;
iv. The date each license
				or certificate expired or expires;
v. Limitations, if any, for each license or
				certificate;
vi. Current status of
				each license or certificate; and
vii. Whether each license or certificate was
				granted by endorsement, examination, or another means;
h. A statement of whether the applicant has
				ever had a licensing authority of another state, district, or territory of the
				United States, or another country or subdivision of another country, deny the
				applicant a license or certificate to practice auricular acupuncture, and if
				so, the name of the jurisdiction denying a license or certificate, date of the
				denial, and an explanation of the circumstances;
i. A statement of whether the applicant has
				ever had a licensing authority of another state, district, or territory of the
				United States, or another country or subdivision of another country, revoke,
				suspend, limit, restrict, or take any other action regarding the applicant's
				license or certificate to practice auricular acupuncture, and if so, the name
				of the jurisdiction taking the action, the action taken, date of the action,
				and an explanation of the circumstances;
j. A statement of whether the applicant has
				ever been convicted of a crime, including driving under the influence of drugs
				or alcohol, other than a minor traffic offense, and if so, the name of the
				jurisdiction in which convicted, the nature of the crime, date of the
				conviction, and current status;
k.
				A statement of whether the applicant has ever had a claim for malpractice or a
				lawsuit filed against the applicant alleging professional malpractice or
				negligence in the practice of auricular acupuncture, and if so, the claim or
				case number, date of the claim or lawsuit, the matters alleged, and whether the
				claim or lawsuit is still pending or the manner in which it was
				resolved;
l. A statement of whether
				the applicant has any condition that may impair the applicant's ability to
				practice auricular acupuncture safely and skillfully, and if so, the nature of
				the condition and any accommodations necessary;
m. A statement of whether the applicant has
				ever resigned, voluntarily or involuntarily, from a health-care facility while
				under investigation, and if so, the name of the health-care facility, the date
				of the resignation, and an explanation of the circumstances; and
n. A statement of whether the applicant has
				ever had a health-care facility terminate, restrict, or take any other action
				regarding the applicant's employment, professional training, or privileges, and
				if so, the name of the health-care facility, the date of the action, and an
				explanation of the circumstances;