Ariz. Admin. Code § 9-16-202

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-16-202 - Application

A. An applicant for licensure shall submit to the Department:

1. An application in a Department-provided format that contains:

a. The applicant's name, home address, telephone number, and e-mail address;

b. The applicant's Social Security number, as required under A.R.S. §§ 25-320 and 25-502;

c. If applicable, the applicant's business addresses and telephone number;

d. The applicant's current employment, if applicable, including:

i. The employer's name,

ii. The licensee's position,

iii. Dates of employment,

iv. The address of the employer,

v. The supervisor's name,

vi. The supervisor's email address, and

vii. The supervisor's telephone number;

e. If applicable, whether the applicant is requesting an audiology license to fit and dispense;

f. Whether the applicant has ever been convicted of a felony or a misdemeanor in this or another state;

g. If the applicant has been convicted of a felony or a misdemeanor:

i. The date of the conviction,

ii. The state or jurisdiction of the conviction,

iii. An explanation of the crime of which the applicant was convicted, and

iv. The disposition of the case;

h. Whether the applicant is or has been licensed as an audiologist, an audiologist to fit and dispense hearing aids, or a speech-language pathologist in another state or country;

i. Whether the applicant has had a license revoked or suspended by any state;

j. Whether the applicant is currently ineligible for licensing in any state because of a license revocation or suspension;

k. Whether any disciplinary action has been imposed by any state, territory or district in this country for an act related to the applicant's practice of audiology or a speech-language pathologist license;

l. Whether the applicant agrees to allow the Department to submit supplemental requests for information under R9-16-214(C);

m. An attestation that the information submitted as part of the application is true and accurate; and

n. The applicant's signature and date of signature;

2. If a license for the applicant has been revoked or suspended by any state documentation that includes:

a. The date of the revocation or suspension,

b. The state or jurisdiction of the revocation or suspension, and

c. An explanation of the revocation or suspension;

3. If the applicant is currently ineligible for licensing in any state because of a license revocation or suspension, documentation that includes:

a. The date of the ineligibility for licensing,

b. The state or jurisdiction of the ineligibility for licensing, and

c. An explanation of the ineligibility for licensing;

4. If the applicant has been disciplined by any state, territory, or district of this country for an act related to the applicant's license to practice audiology or a speech-language pathologist license that is consistent with A.R.S. Title 36, Chapter 17, documentation that includes:

a. The date of the disciplinary action,

b. The state or jurisdiction of the disciplinary action,

c. An explanation of the disciplinary action, and

d. Any other applicable documents, including a legal order or settlement agreement;

5. Documentation of the applicant's citizenship or alien status that complies with A.R.S. § 41-1080; and

6. A fee specified in R9-16-216.

B. In addition to complying with subsection (A), an applicant that may be eligible for licensure under A.R.S. § 36-1922 shall submit documentation to the Department that includes:

1. The name of each state that issued the applicant a current license, including:

a. The license number of each current license, and

b. The date each current license was issued;

2. Documentation of the professional license or certification issued to the applicant by each state in which the applicant holds a professional license or certification;

3. For each state named in subsection (B)(1), a statement, signed and dated by the applicant, attesting that the applicant:

a. Has been licensed or certified in another state for at least one year, with a scope of practice consistent with the scope of practice for which licensure is being requested;

b. Has met minimum education requirements according to A.R.S. §§ 36-1940 or 36-1940.01;

c. Has not voluntarily surrendered a license or certification in any other state or country while under investigation for unprofessional conduct; and

d. Does not have a complaint, allegation, or investigation pending before another regulatory entity in another state or country related to unprofessional conduct.

C. The Department shall review the application and required documentation for a license according to R9-16-214 and Table 2.1.

Ariz. Admin. Code § R9-16-202

Former Section R9-16-202 repealed, new Section R9-16-202 adopted effective January 23, 1978 (Supp. 78-1). Repealed effective March 14, 1994 (Supp. 94-1). Adopted by final rulemaking at 5 A.A.R. 4359, effective October 28, 1999 (Supp. 99-4). Amended by exempt rulemaking at 20 A.A.R. 1998, effective 7/1/2014. Adopted by final expedited rulemaking at 26 A.A.R. 816, effective 4/8/2020.