Section R4-24-207. Application for a Physical Therapist Assistant Certificate

A.      An applicant for an original physical therapist assistant certifi- cate shall submit to the Board an application packet that includes:

1.        An application form provided by the Board, signed, dated, and verified by the applicant that contains:

a.         The applicant’s name, business and residential addresses, telephone number, birth date, and Social Security number;

b.        The name and address of the college or university where the applicant completed an accredited educa- tional program for physical therapist assistants, dates of attendance, and date of completion;

c.         A statement of whether the applicant has ever been licensed or certified as a physical therapist assistant in any other jurisdiction of the United States or for- eign country;

d.        Professional employment history for the five years before the date of application including the name, address, and telephone number for each place of employment, job title, description of the work com- pleted, and explanation of any breaks in employ- ment, if applicable;

e.         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;

f.         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;

g.        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;

h.        A statement of whether the applicant has ever been the subject of disciplinary action by a professional association or postsecondary educational institution;

i.         A statement of whether the applicant has committed any of the actions referenced in the definition of good moral character in R4-24-101;

j.         A statement of whether the applicant has ever had a malpractice judgment or has a lawsuit currently pending for malpractice and if so, an explanation;

k.        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;

l.         A statement of whether the applicant has any impair- ment to the applicant’s cognitive, communicative, or physical ability to participate in therapeutic inter- ventions with skill and safety and if so, an explana- tion;

m.       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 participate in therapeutic interventions with skill and safety and if so, an explanation;

n.        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 partici- pate in therapeutic interventions with skill and safety and if so, an explanation;

o.        A statement of whether the applicant has ever vio- lated A.R.S. § 32-2044(10); and

p.        A sworn statement by the applicant verifying the truthfulness of the information provided by the applicant;

2.        A passport photograph of the applicant no larger than 1 1/ 2 x 2 inches that was taken not more than six months before the date of the application;

3.        Evidence of the applicant’s U.S. citizenship, alien status, legal residency, or lawful presence in the U.S.; and

4.        The fee required in R4-24-107.

B.       In addition to the requirements in subsection (A), an applicant shall arrange to have directly submitted to the Board:

1.        An official transcript or letter showing that the applicant completed all requirements of an accredited educational program that includes the official seal of the school or college where the applicant completed the accredited educational program and signature of the registrar of the school or college;

2.        Verification of passing a national examination for physi- cal therapist assistants as evidenced by an original notice of examination results; and

3.        Verification of passing a jurisprudence examination as evidenced by an original notice of examination results.

C.      In addition to the requirements in subsections (A) and (B), an applicant for a physical therapist assistant certificate by endorsement shall submit to the Board:

1.        The name of the licensing or certifying agency of any jurisdiction in which the applicant is currently or has been previously licensed or certified; and

2.        A verification of license or certificate, signed and dated by an official of the agency licensing or certifying the applicant, that includes the official seal of the licensing or certifying agency and all of the following:

a.         The name of the applicant;

b.        The license or certificate number and date of issu- ance;

c.         The current status of the license or certificate;

d.        The expiration date of the license or certificate;

e.         A statement of whether the applicant was ever denied a license or certificate by the agency and if so, an explanation; and

f.         A statement of whether any disciplinary action is pending or has ever been taken against the applicant and if so, an explanation.

D.      The Board shall deny a certificate to an applicant who fails to meet the requirements of this Section or A.R.S. Title 32, Chap- ter 19. A person denied a certificate may request a hearing under A.R.S. Title 41, Chapter 6, Article 10.

Historical Note

New Section adopted by final rulemaking at 5 A.A.R. 2988, effective August 12, 1999 (Supp. 99-3). Former Section R4-24-207 renumbered to R4-24-209; new Sec- tion R4-24-207 renumbered from R4-24-205 and amended by final rulemaking at 6 A.A.R. 2399, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking

at 12 A.A.R. 2401, effective August 5, 2006 (Supp. 06-2). Amended by final rulemaking at 14 A.A.R. 376, effective March 8, 2008 (Supp. 08-1). Amended by final rulemak-

ing at 14 A.A.R. 3418, effective October 4, 2008, (Supp.

08-3).