Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 21 - BOARD OF OPTOMETRY › Article 2 - LICENSING PROVISIONS › Section R4-21-201 - Licensure by Examination

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				individual is eligible to apply for licensure by examination if the individual
				graduated from an accredited optometry program but is not eligible for
				licensure by endorsement under
				R4-21-202(A).
B. To apply for licensure by examination, an
				individual who is eligible under subsection (A) shall submit an application
				form, which is available from the Board, and provide the following information
				about the applicant:
1. Full legal
				name;
2. Other names ever used, if
				any, and if applicable, a copy of the court document or marriage license
				resulting in a name change;
3.
				Social Security number;
4. Mailing
				address;
5. E-mail address, if
				any;
6. Residential, business, and
				mobile telephone numbers, if applicable;
7. Date and place of birth;
8. Residential addresses for the past five
				years;
9. Educational background
				including the name and address of, dates of attendance at, and date of
				graduation from:
a. An accredited optometry
				program,
b. A pre-optometric school
				or undergraduate educational institution, and
c.
				Other post-secondary schools attended, if any;
10. Experience in the practice of the
				profession of optometry including the business form and location of the
				practice;
11. Work experience or
				occupation, other than the practice of the profession of optometry, for the
				past five years;
12. List of the
				states in which the applicant is professionally licensed including the name of
				the state, type of professional license, date issued, and expiration
				date;
13. List of the states in
				which the applicant was but no longer is professionally licensed including the
				name of the state, type of professional license, date issued, and reason the
				license is no longer valid;
14.
				Statement of whether the applicant:
a. Has
				ever been denied the right to take an examination for optometric licensure by
				any state or jurisdiction and if so, the name of the state or jurisdiction,
				date, and reason for the denial;
b.
				Has ever been denied an optometric license or renewal in any state or
				jurisdiction and if so, the name of the state or jurisdiction, date, and reason
				for the denial;
c. Has ever had a
				license or certificate of registration to practice the profession of optometry
				suspended or revoked by any optometric licensing agency and if so, the name of
				the optometric licensing agency, date, reason for the suspension or revocation,
				and current status;
d. Has ever had
				an investigation conducted or has an investigation pending by an optometric
				regulatory agency of any state or jurisdiction and if so, name of the
				optometric regulatory agency and state or jurisdiction, date, reason for the
				investigation, and current status;
e. Has ever had a disciplinary action
				instituted against the applicant by any optometric licensing agency and if so,
				the name of the optometric licensing agency, date, nature of the disciplinary
				action, reason for the disciplinary action, and current status;
f. 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, name of the jurisdiction, date, offense charged, offense for which
				convicted, pled guilty, or no contest, and current status;
g. Is currently, or has ever been addicted to
				narcotic substances or habitually abused alcohol within the last 10 years. If
				so, dates during which the addiction or abuse occurred, steps taken to address
				the addiction or abuse, current status, and a statement as to why the addiction
				or abuse does not amount to unprofessional conduct.
15. Dated and sworn
				signature of the applicant verifying that the information provided is true to
				the best of the applicant's knowledge, information, and belief.