Section R4-21-201. Licensure by Examination

A.       An individual is eligible to apply for licensure by examination if the individual graduated from an accredited optometry pro- gram 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;

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 educa- tional institution,

c.         High school, and

d.        Other post-secondary schools attended;

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 profes- sional 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type of professional license, date issued, and reason the license is no longer valid;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 examina- tion for optometric licensure by any state or jurisdic- tion 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 juris- diction, date, reason for the investigation, and cur- rent 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, rea- son 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 cur- rent status;

g.        Has been addicted to narcotic substances or habitu- ally abused alcohol within the last 10 years and if so,

	date, steps taken to address the addiction or abuse,		4.     Has not had a license to practice the profession of optom-
	and current status; and		etry suspended or revoked by any licensing jurisdiction
	h.     Is presently addicted to narcotic substances or habit-		for a cause that is a ground for suspension or revocation
	ually abuses alcohol and if so, why the addiction or		of a license in Arizona.
	abuse does not amount to unprofessional conduct;	B.	To apply for licensure by endorsement, an individual who is
	and		eligible under subsection (A) shall submit the application form
	15.  Dated and sworn signature of the applicant verifying that		described in R4-21-201(B).
	the information provided is true to the best of the appli-	C.	In addition to complying with subsection (B), an applicant for
	cant’s knowledge, information, and belief.		licensure by endorsement shall submit or have submitted on
C.	In addition to submitting the application form required under		the applicant’s behalf:
	subsection (B), an applicant shall submit or have submitted on		1.     The materials required under R4-21-201(C)(1) through
	the applicant’s behalf:		(C)(4) and (C)(6) through (C)(10);
	1.     A 2 inch by 3 inch passport-quality photograph of the		2.     A state board certification and license verification form,
	applicant’s head and shoulders that is taken within six		which is submitted directly to the Board from the state
	months of the date of application and signed by the appli-		that issued the license on which the applicant’s endorse-
	cant in ink across the lower portion of the front side;		ment application is based, indicating:
	2.     A full set of readable fingerprints taken by a criminal jus-		a.      Name and title of the individual completing the veri-
	tice agency;		fication form;
	3.     A cashier’s check or money order payable to the Arizona		b.     Number of the applicant’s optometry license in the
	Department of Public Safety in the amount required to		state;
	obtain a state and federal criminal records check;		c.      Date on which the applicant was issued an optome-
	4.     The application fee required under A.R.S. § 32-1727;		try license by the state;
	5.     A copy of the scores obtained by the applicant on Parts I,		d.     A statement of whether the applicant:
	II, and III of the National Board of Examiners in Optome-		i.      Has been licensed in the state for at least four of
	try examination taken less than 10 years before the date		the last five years;
	of the application;		ii.     Is certified to use topical diagnostic, topical
	6.     A passing score obtained by the applicant on the jurispru-		therapeutic, or oral pharmaceutical agents and
	dence examination described at R4-21-203;		if so, the date on which the certification was
	7.     An official transcript submitted directly to the Board by		obtained;
	the educational institution with an accredited optometry		iii.   Is currently in good standing in the state;
	program  from  which  the  applicant   graduated  with   a		iv.   Is known to be licensed to practice the profes-
	degree in optometry;		sion of optometry in another state and if so, the
	8.     An official transcript submitted directly to the Board by		name of the other state;
	the educational institution at which the applicant took		v.         Has been subject to any disciplinary action and
	pre-optometry or undergraduate courses;		if so, the date, nature of, and reason for the dis-
	9.     A self-query from the National Practitioner Data Bank-		ciplinary action; and
	Healthcare  Integrity   and  Protection  Data  Bank  made		vi.   Is subject to any pending investigation or com-
	within three months before the date of application; and		plaint and if so, the nature of the investigation
	10.  A copy of the front and back of the cardiopulmonary		or complaint; and
	resuscitation card issued to the applicant or other written		e.      The  dated,  notarized   signature  of  the  individual
	documentation of current certification in cardiopulmo-		completing the verification form; and

nary resuscitation.

Historical Note

Adopted effective February 7, 1986 (Supp. 86-1).

Amended effective April 1, 1991 (Supp. 91-2). Amended

effective November 5, 1998 (Supp. 98-4). Amended by final rulemaking at 6 A.A.R. 3812, effective September 13, 2000 (Supp. 00-3). Amended by final rulemaking at

11 A.A.R. 1864, effective May 3, 2005 (Supp. 05-2). Amended by final rulemaking at 14 A.A.R. 12, effective February 2, 2008 (Supp. 07-4). Amended by final rule-

making at 16 A.A.R. 2383, effective November 16, 2010

(Supp. 10-4).