Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 24 - BOARD OF PHYSICAL THERAPY › Article 2 - LICENSING PROVISIONS › Section R4-24-201 - Application for a Physical Therapist License

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant for a physical therapist
				license shall submit to the Board an application packet that includes:
1. An application form provided by the Board
				that is signed, dated, and verified by the applicant and 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 each university or
				college attended by the applicant, the dates of attendance, and the date of
				graduation and degree received, if applicable;
c. The name and address of the university or
				college where the applicant completed an accredited educational program and
				dates of attendance;
d. A statement
				of whether the applicant has ever been licensed as a physical therapist in any
				other jurisdiction of the United States or foreign country;
e. Professional employment history for the
				past five years, 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;
f. 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;
g. 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;
h. 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;
i. A statement of
				whether the applicant has ever been the subject of disciplinary action by a
				professional association or post-secondary educational institution;
j. A statement of whether the applicant has
				committed any of the actions referenced in the definition of good moral
				character in
				R4-24-101;
k. A statement of whether the applicant has
				ever had a malpractice judgment, has a lawsuit currently pending for
				malpractice, or entered into a settlement from a malpractice suit and if so, an
				explanation;
l. 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;
m. A statement of
				whether the applicant has any impairment to the applicant's cognitive,
				communicative, or physical ability to engage in the practice of physical
				therapy with skill and safety and if so, an explanation;
n. 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 practice physical therapy with skill and safety and if
				so, an explanation;
o. 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 practice physical therapy with skill and safety and if
				so, an explanation;
p. A statement
				of whether the applicant has ever violated A.R.S. §
											32-2044(10);
				and
q. A statement by the applicant
				attesting to the truthfulness of the information provided by the applicant;