Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 08 - ACUPUNCTURE BOARD OF EXAMINERS › Article 2 - ACUPUNCTURE LICENSING; VISITING PROFESSOR CERTIFICATE › Section R4-8-203 - Application for Acupuncture License

Current through Register Vol. 30, No. 28, July 12, 2024
A. To be licensed to practice acupuncture, 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 a health-care profession in this or
				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 a health-care
				profession;
ii. The number of each
				license;
iii. The date each license
				was issued;
iv. The date each
				license expired or expires;
v.
				Limitations, if any, for each license;
vi. Whether each license was granted by
				endorsement, examination, or another means;
h. A statement of whether the applicant is
				certified by the NCCAOM, and if so, whether the certification is active and
				current, and the dates of issuance and expiration;
i. If not certified by the NCCAOM, a
				statement of whether the applicant:
i. Has
				passed all the following NCCAOM modules: Point Location; Foundations of
				Oriental Medicine; Bio-medicine; and Acupuncture; or
ii. Has passed the State of California
				Acupuncture Licensing Examination;
j. A statement of whether the applicant has
				completed an acupuncture program accredited within the United States or another
				country or subdivision of another country, and if so, the date of program
				completion;
k. 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
				acupuncture, and if so, the name of the jurisdiction denying a license or
				certificate, date of the denial, and an explanation of the
				circumstances;
l. 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 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;
m. 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;
n.
				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 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;
o. A statement of whether the applicant has
				any condition that may impair the applicant's ability to practice acupuncture
				safely and skillfully, and if so, the nature of the condition and any
				accommodations necessary;
p. 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
q. 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;