Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 24 - BOARD OF PHYSICAL THERAPY › Article 2 - LICENSING PROVISIONS › Section R4-24-207 - Application for a Physical Therapist Assistant Certificate

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant for an original physical
				therapist assistant certificate shall submit to the Board an application packet
				that includes:
1. An application form
				provided by the Board, signed, dated, and verified by the applicant that
				contains:
a. The applicant's name, business,
				residential, and e-mail addresses, business and residential telephone numbers,
				birth date, and Social Security number;
b. The name and address of the college or
				university where the applicant completed an accredited educational program for
				physical therapist assistants, dates of attendance, and date of
				completion;
c. A statement of
				whether the applicant has ever been licensed or certified as a physical
				therapist assistant in any other jurisdiction of the United States or foreign
				country;
d. Professional employment
				history for the five years before the date of application including the name,
				address, and telephone number for each place of employment, job title,
				description of the work completed, and explanation of any breaks in employment,
				if applicable;
e. A statement of
				whether the applicant has ever been convicted of, pled guilty or no contest to,
				or entered into diversion in lieu of prosecution for any criminal offense in
				any jurisdiction of the United States or foreign country and if so, an
				explanation;
f. A statement of
				whether the applicant has ever had an application for a professional or
				occupational license, certificate, or registration, other than a driver's
				license, denied, rejected, suspended, or revoked by any jurisdiction of the
				United States or foreign country and if so, an explanation;
g. A statement of whether the applicant is
				currently or ever has been under investigation, suspension, or restriction by a
				professional licensing board in any jurisdiction of the United States or
				foreign country for any act that occurred in that jurisdiction that would be
				the subject of discipline under this Chapter and if so, an
				explanation;
h. A statement of
				whether the applicant has ever been the subject of disciplinary action by a
				professional association or postsecondary educational institution;
i. A statement of whether the applicant has
				committed any of the actions referenced in the definition of good moral
				character in
				R4-24-101;
j. A statement of whether the applicant has
				ever had a malpractice judgment or has a lawsuit currently pending for
				malpractice and if so, an explanation;
k. A statement of whether the applicant is
				currently more than 30 days in arrears for payment required by a judgment and
				order for child support in Arizona or any other jurisdiction;
l. A statement of whether the applicant has
				any impairment to the applicant's cognitive, communicative, or physical ability
				to participate in therapeutic interventions with skill and safety and if so, an
				explanation;
m. A statement of
				whether the applicant has, within the past 10 years, used alcohol, any illegal
				chemical substance, or prescription medications, that in any way has impaired
				or limited the applicant's ability to participate in therapeutic interventions
				with skill and safety and if so, an explanation;
n. A statement of whether the applicant has,
				within the past 10 years, been diagnosed as having or is being treated for
				bipolar disorder, schizophrenia, paranoia, or other psychotic disorder that in
				any way has impaired or limited the applicant's ability to participate in
				therapeutic interventions with skill and safety and if so, an
				explanation;
o. A statement of
				whether the applicant has ever violated A.R.S. §
											32-2044(10);
				and
p. A sworn statement by the
				applicant verifying the truthfulness of the information provided by the
				applicant;