Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 45 - Board of Respiratory Care Examiners › Article 2 - LICENSURE › Section R4-45-201 - Application

Current through Register Vol. 30, No. 28, July 12, 2024
A.In addition to
				meeting the qualifications listed in A.R.S. §
									32-3523(A),
				an applicant for a license to practice as a respiratory care practitioner shall
				submit the following information on the Board's license application form:
1. The applicant's full name and Social
				Security number;
2. The applicant's
				current mailing, permanent and e-mail addresses;
3. The applicant's current employer's name,
				address, and telephone number;
4.
				The applicant's current employment position and beginning date of
				employment;
5. The applicant's
				current supervisor's name and telephone number;
6. The applicant's area of care or
				specialty;
7. The applicant's birth
				date;
8. The applicant's home and
				work telephone numbers;
9. Any name
				by which the applicant has ever been known. The applicant shall submit
				documentation of name change if the applicant is applying for licensure under a
				name different from that on the applicant's credentials, educational degree, or
				diploma;
10. A statement of the
				facts entitling the applicant to take the RRT examination, to receive a license
				without examination under
				R4-45-206;
11. The name of any state or province in
				which the applicant has been granted a certification, registration, or license
				as a respiratory care practitioner; including the number, date issued,
				expiration date, and a statement whether that certificate, registration, or
				license has ever been the subject of discipline, censure, probation, practice
				restriction, suspension, revocation, or cancellation;
12. A statement whether the applicant has
				ever been denied a professional license or certificate or the privilege of
				taking an examination by a governing licensing authority and, if the answer is
				yes, a complete explanation of the denial including date, state or province,
				and a copy of any order issued;
13.
				A statement whether the applicant is the subject of any pending disciplinary
				action that is directly or indirectly related to the practice of respiratory
				therapy and, if the answer is yes, a complete explanation, including date,
				state or province, and a copy of any order issued;
14. A statement whether the applicant has
				ever voluntarily surrendered a professional license and, if the answer is yes,
				a complete explanation, including dates, state or province, and a copy of any
				order issued;
15. A statement
				whether the applicant has ever filed an application for a respiratory care
				practitioner license in Arizona and, if the answer is yes, the date;
16. A statement whether the applicant has
				been enrolled in or committed to a substance-abuse or alcohol-treatment program
				in the past 10 years and, if the answer is yes, a complete explanation,
				including date, place, and a copy of any documentation of completion of the
				program;
17. Except for a minor
				traffic violation, a statement whether the applicant has ever been convicted
				of, pled no contest (nolo contendere) to, entered into any agreement concerning
				an arrest or charge (even if the agreement resulted in a dismissal or
				expungement of record), or has an outstanding arrest or charge for any
				violation of any law of any state of the United States, or a foreign country
				and, if the answer is yes, a complete explanation, including place, date, and a
				copy of any pertinent documentation such as a court order or plea
				agreement;
18. A statement whether
				the applicant has had an intemperance to drugs or alcohol within the last 10
				years and, if the answer is yes, a complete explanation;
19. The applicant's physical description,
				including height, weight, and eye and hair color;
20. The highest level of education completed
				by the applicant;
21. Evidence of
				the applicant's U.S. citizenship, alien status, legal residency, or lawful
				presence in the U.S.;
22.
				Consistent with the Board's authority under A.R.S. §
										32-3522(B)(4),
				other information or documentation the Board determines is necessary to
				evaluate the applicant fully;
23. A
				record or documentation release; and
24. The applicant's certification that the
				information provided is true and complete and that the applicant has not
				engaged in any act prohibited by Arizona law or this Chapter.