Ariz. Admin. Code § R4-25-301 - Application for a Regular Podiatry License

A. An applicant for a regular license shall submit:

1. An application form approved by the Board, signed and dated by the applicant that contains questions approved by the Board.

a. The applicant's name, address, social security number, telephone number, and date of birth;

b. The name and address of the applicant's employer at the time of application;

c. The name, address, and type of facility at which the applicant served as an intern or resident in podiatric medicine;

d. The name and address of each university or college from which the applicant graduated, dates of attendance, date of graduation, and degree received;

e. The name and address of the podiatric medical school from which the applicant graduated, dates of attendance, and date of graduation;

f. The name of each state or jurisdiction in which the applicant is currently or has been licensed as a podiatrist and address of the licensing agency;

g. A statement of whether the applicant has taken and passed a national podiatric examination in any state and date of passage, if applicable;

h. A statement of whether the applicant has ever been convicted of a felony or misdemeanor involving moral turpitude;

i. A statement of whether the applicant has ever had an application for a license, certification, or registration, other than a driver's license, denied or rejected by any state or jurisdiction;

j. A statement of whether the applicant has ever had a license, certification, or registration, other than a driver's license, suspended or revoked by any state or jurisdiction;

k. A statement of whether the applicant has ever entered into a consent agreement or stipulation with any state or jurisdiction;

l. A statement of whether the applicant has ever been named as a defendant in any medical malpractice matter that resulted in a settlement or judgment against the applicant;

m. A statement of whether the applicant has any medical condition that in any way impairs or limits the applicant's ability to practice podiatric medicine; and

n. A statement, verified under oath by the applicant, that the information on the application pertains to the applicant, is true and correct, and was not procured through fraud or misrepresentation.

o. A statement of whether the applicant has taken at least three hours of opioid related clinical education if applicant was enrolled in a public or private medical program in Arizona.

2. Two passport-type photographs of the applicant taken not more than six months before the date of application;

3. A photocopy of the diploma issued to the applicant upon completion of podiatric school;

4. A photocopy of the residency certificate issued to the applicant upon completion of residency; and

5. The fee required in R4-25-103.

B. An applicant shall arrange to have a transcript of examination scores of a national board examination in podiatry sent directly to the Board office by the professional examination service preparing the examination.

Notes

Ariz. Admin. Code § R4-25-301

Adopted effective August 30, 1978 (Supp. 78-4). Amended effective April 3, 1980 (Supp. 80-2). Former Section R4-25-30 renumbered without change as Section R4-25-301 effective November 18, 1986 (Supp. 86-6). Section repealed effective July 27, 1995 (Supp. 95-3). New Section adopted by final rulemaking at 5 A.A.R. 1000, effective March 16, 1999 (Supp. 99-1). Amended by final rulemaking at 26 A.A.R. 1501, effective 9/6/2020. Amended by final rulemaking at 29 A.A.R. 1551, effective 8/18/2023.