ࡱ> ] bjbjZ!Z!  8K4\8K4\a%r r 86*sH(&"HHHrrrrrrr$ux sQ("(( sHHZs...(HHr.(r..6JPHoNL(Nrps0sO~y-~y8PP8~yP"!.#% s s>.s((((~yr > : Requirements for Naturopathic Medical Licensure in the State of Arizona READ CAREFULLY: FEES ARE NON-REFUNDABLE Please review the requirements for licensure under the Arizona Revised Statutes and Rules prior to applying. The information is available on the website  HYPERLINK "http://www.aznd.gov" www.aznd.gov Once your application has been received and reviewed, the Board will send you ONE NOTICE OF INCOMPLETENESS indicating any required materials that have not yet been received. The notice is typically sent via email, so make certain the Board has your current email address. The Board shall consider an application withdrawn if within 365 days from the sending of the incomplete notice, the applicant fails to supply the missing information requested in the notice. The filing of an application grants the Board the authority to obtain information from any licensing Board or agency in any State, district, territory or county of the United States or another country, from the Arizona Criminal Justice information system in the Department of Public Safety and from the Federal Bureau of investigations. As required by R4-18-201, R4-18-202 Successful completion of the Jurisprudence Examination is a requirement for licensure. If you have not already taken the examination, arrangements can be made by contacting the Board office. A.R.S. 1-501 requires, in general, that a person applying for a license must submit documentation to the licensing agency that satisfactorily demonstrates that the applicant is lawfully present in the United States. Pursuant to A.R.S. 32-1522 A. To be eligible for a license to practice naturopathic medicine pursuant to this chapter, the applicant shall: Be a graduate of an approved school of naturopathic medicine. (A list of approved naturopathic medical schools is available on the website www.aznd.gov) Have satisfactorily completed an approved internship, preceptorship or clinical training program in naturopathic medicine. Possess a good moral and professional reputation. Be physically and mentally fit to practice as a doctor of naturopathic medicine. Not be guilty of any act of unprofessional conduct or any other conduct which would be grounds for refusal, suspension or revocation of a license under this chapter. Not have had a license to practice any profession refused, revoked or suspended by any other state, district or territory of the United States or another country for reasons which relate to his ability to skillfully and safely practice as a physician in this state. File a completed application pursuant to section 32-1524 and pass the examination provided for in section 32-1525 B The Board may: Require an applicant to submit credentials or other written or oral proof, and make investigations it deems proper to adequately advise the Board with respect to the qualifications of an applicant. Check List for Applicant __Yes __No (Required for all applicants) I have enclosed with this application a passport size photograph and have printed my name on the back of the photograph. Photograph must have been taken within the last 60 days. __Yes __No (Required for all applicants) I have requested an official copy of my transcript issued by my naturopathic medical school, to be sent to the Board. __Yes __No (Required for all applicants) I have requested official transcripts from NPLEX showing passing grades in I and II plus required add on(s) be sent to the Board. __Yes __No (Required for all applicants) I have enclosed with this application my fingerprint card completed by a fingerprint technician, along with the required fee. A MONEY ORDER in the amount of $22.00 payable to DPS is required by the applicant. This fee is not refundable. Finger print clearance cards are not accepted. The Board does not process fingerprint cards. DPS processes the card and transmits the card to the United States Department of Justice Federal Bureau of Investigation. That Bureau reads the fingerprints and provides a Criminal Justice Information Report to the Board. __Yes __No (Required for all applicants) I took and passed the Jurisprudence Examination on _____/_____/______. Or have made arrangements to take the Examination on ____ /_____/______. __Yes __No (All applicants if applicable) I have completed the Pharmacology requirements as outlined in A.R.S. 32-1525(E) __Yes __No (Required for all applicants) Citizenship /Alien Status Documentation Required State Law (A.R.S. 1-501) All applicants must submit documentation regarding their citizenship/nationality/alien status with their application. See List A & B on our website for specific documentation required. __Yes __No (Applicants for reinstatement) provided 30 hours of CME for the year you are applying for reinstatement. CME must fall under the guidelines outlined in the rules section on the website www.aznd.gov __Yes __No (All applicants) Included application fee. $225.00 money order payable to AZND Board  State of Arizona Naturopathic Physicians Medical Board Protecting the Publics Health 1400 W. Washington, Ste 230 Phoenix, AZ 85007 Phone: 602-542-8242 Fax: 602-542-3093 Email:  HYPERLINK "mailto:Info@azmd.gov" Info@aznd.gov Website: www.aznd.gov APPLICATION FOR NATUROPATHIC MEDICAL LICENSE APPLICATION FEE $225.00 THIS APPLICATION AND ANY DOCUMENT SUBMITTED WITH THIS APPLICATION BECOMES THE PROPERTY OF THE STATE OF ARIZONA AND IS NOT RETURNED TO THE APPLICANT. FEES ARE NONREFUNDABLE. INCOMPLETE OR UNREADABLE APPLICATIONS ARE DENIED BY THE BOARD. Alternative format of Submitting This Application An individual with a disability who, as a result of that disability, requires this application in an alternative format may contact the Boards Americans with Disability coordinator at Voice Telephone Number (602) 542-3095, or through Voice Replay Service at (800) 842-4681 or the TTY Service at (800) 367-8939 to make the need known. This Application is for: [ ] Regular Medical License (License by Exam) [ ] Medical License by Endorsement from the State/Province of _____________________________ [ ] I am requesting a temporary license upon application completion. I understand a temporary license is valid until the last day of the month in which my application is presented to the Board for approval. Applicants Name: ____________________________________________________________________________ Last First Middle (Maiden) Office Address: _____________________________________________________Ste. #_____________________ City: ___________________________, State: ________________________ ZIP Code: _____________________ Business Name: (if any):________________________________________________________________________ Office Phone:(____)_______________Office Fax: (____)____________Office Email:________________________ Home Address:_____________________________________________________________Apt. #_____________ City: ___________________________________, State: _____________________ Zip Code: ________________ Cell Number (______) _______________________ Telephone: (_______) ________________________________ Email Address:________________________________________________________________________________ Mailing Address:_____________________________________________________________Apt. /Ste#_____________ City: ___________________________________, State: _____________________ Zip Code: ________________ Date of Birth: _______/_______/_______Place of Birth: ________________________________________________ City State/ Country Social Security Number_____________-________________-___________________ Male____ Female_______ Height: _________ Weight:_________ Hair Color: __________ Eye Color:______________ Office Use ReceiptedProcessedEmailedAgendaBoard Use: Type of documentation submitted Date Issued: Any Expiration Date:Medical School Information Name / address of Medical School from Which Applicant Graduated: ______________________________________________ _________________________________________________________Date Graduated:__________/___________/___________ Name and address of Clinical Training Facility:__________________________________________________________________ ______________________________ Date of clinical training completion:_____________________________________________ ____ I have requested my official transcripts to be sent directly to: The Naturopathic Physicians Medical Board National Examination Information Pursuant to A.R.S. 32-1525, an applicant for licensure in the State of Arizona must take and pass the North American Board of Naturopathic Examiners (NABNE) NPLEX examination. Part One: I took and passed the NABNE Basic Sciences Examination on _______/________/_________. Part Two: I took and passed the NABNE Clinical Science Examination on ________/________/_________. C. ADD ON(s):I took and passed NABNE Acupuncture and Minor surgery Examination(s) on _______/_______/_______ ____ I have requested my official NABNE transcripts to be sent directly to: The Naturopathic Physicians Medical Board ________________________________________________________________________________________________________________YOU MUST COMPLETE IF APPLYING VIA ENDORSEMENT Pursuant to 32-1523. you must meet the following requirements if applying via endorsement. 3. Be actively engaged, for at least three years immediately preceding the application, in one or more of the following: (a) Active practice as a doctor of naturopathic medicine. (b) An approved internship, preceptorship or clinical training program in naturopathic medicine. (c) An approved postdoctoral training program in naturopathic medicine. (d) The resident study of naturopathic medicine at an approved school of naturopathic medicine. HOW ARE YOU MEETING THE QUALIFICATIONS FOR LICENSURE BY ENDORSEMENT. INCLUDE THE DATES OF LICENSE AND CERTIFICATION(S) HELD. I meet the qualifications under (a) _______ How_________________________________________________________________ I meet the qualifications under (b) _______ How_________________________________________________________________ I meet the qualifications under (c) _______ How_________________________________________________________________ I meet the qualifications under (d) _______ How_________________________________________________________________ HOW ARE YOU MEETING THE PHARMACOLOGY QUALIFICATIONS FOR LICENSURE BY ENDORSEMENT Pursuant to A.R.S. 32-1525(4): If applicant was licensed in another state or Canadian province BEFORE January 1, 2005 applicant is required to provide evidence of completion of an additional 60 hours course and examination in pharmacotherapeutics. R4-18-902 required the 60 hour course to be offered, approved, or recognized by one of the following organizations. Education certified as category 1 by an organization accredited by the Accreditation Council on Continuing Medical Education or accredited by the American Association of Naturopathic Physicians, The Arizona Naturopathic Medical Association or any naturopathic licensing authority in the United States of Canada. I Graduated AFTER January 1, 2005 _______ I am not required to present evidence of completion of the additional course. I Graduated Before January 1, 2005 _______ I meet the pharmacotherapeutics requirement by presenting evidence of completion of a 60 hour course and examination offered, approved or accredited by ____ ACCME _____ AANP ____ AzNMA _____ naturopathic licensing authority. Include proof of completion. ________________________________________________________________________________________________________________ List in Chronological order all colleges and universities attended, location, dates of attendance and credits or degree earned: (If additional space is needed, attach a supplement to this application. Do not list your naturopathic college.) College or UniversityDates AttendedCredits or Degree EarnedList ALL licenses and certificates issued or denied by any licensing agency: (If additional space is needed, attach a supplement to this application.) Applicants are required to request each agency listed below to verify the status of the license or certificate. The document for requesting said information is enclosed with this application. It may be copied as needed. Name of Licensing AgencyLocationStatus of License or CertificateNext Renewal Date ARIZONA STATEMENT OF CITIZENSHIP OR ALIEN STATUS FOR STATE PUBLIC BENEFITS Professional License and Commercial License Arizona Naturopathic Physicians Medical Board Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. 1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a professional license and commercial license issued by a State agency is a State public benefit. Arizona Revised Statutes 41-1080 requires, in general, that a person applying for a license must submit documentation to the license agency that satisfactorily demonstrates the applicants presence in the United States is authorized under federal law. Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals must also complete Section III. Submit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S. National Status, or Alien Status" with your application for license or renewal. If the document you submit does not contain a photograph, you must also provide a government issued document that contains your photograph. You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your current legal name. SECTION I - Applicant's Name_____________________________________________________ SECTION II - CITIZENSHIP OR NATIONAL STATUS DECLARATION Evidence showing U.S. citizen or U.S. national status includes the following: Primary Evidence: An Arizona driver license issued after 1996 or an Arizona nonoperating identification license issued after 1996, A United States birth certificate United States passport; (4) A foreign passport with a United States visa. (5) A United States citizenship and immigration services employment authorization document or refugee travel document. See Arizona Revised Statutes 41-1080 for a complete list Are you a citizen or national of the United States? o Yes o No If you answered yes, 1) Attach a legible copy of a document from the attached list. 2) Name of Document___________________________________________________________________ 3) Go to section IV. If you answered No, you must complete Section III and IV SECTION III-ALIEN STATUS DECLARATION To be completed by applicants who are not citizens or nationals of the United States. Indicate alien status by checking the appropriate box. Attach a legible copy of a document from the attached list or other document as evidence of your status. Name of document provided_______________________________________________________ Qualified Alien Status (8 U.S.C. 1621(a)(1),-1641(b) and (c)), Nonimmigrant Status (8 U.S.C. 1621(a)(2)), Alien Paroled into the United States For Less Than One Year (8 U.S.C. 1621(a)(3)), Other Persons (8 U.S.C 1621(c)(2)(A) and (C) SECTION IV - Declaration ALL APPLICANTS MUST COMPLETE THIS SECTION I declare under penalty of perjury under the laws of the state of Arizona that the answers and evidence I have given are true and correct to the best of my knowledge. ______________________________________ Signature of Applicant YOU ARE REQUIRED TO ANSWER ALL OF THE FOLLOWING QUESTIONS. NOTE: In the event the response to any of the questions number 1 through 9 is YES, the applicant must file with the application a detailed written supplement concerning the date of event, including any charge, date of such charge, the complete name and address of all bodies of jurisdiction, the results of any charges, and the disposition of such charges. The Fact that a conviction and/or criminal offense has been pardoned, expunged or dismissed, or that your civil rights have been restored does not mean that you can answer No to the questions. __Yes __No 1. Have you ever been arrested, charged with, convicted of, or entered into a plea of no contest to a felony or a misdemeanor? __ Yes __No 2. Have you ever had a license/certificate, including a drivers license, denied, suspended, rejected or revoked by any agency? __ Yes __No 3. Have you ever been disciplined by any agency for any act of unprofessional conduct as defined in Arizona Revised Statutes, Section 32-1501? __ Yes __No 4. In lieu of disciplinary action by an agency, have you ever entered a consent agreement or stipulation with a licensing agency? __ Yes __No 5. Do you have a complaint pending before any agency? __ Yes __No 6. Have you ever been found guilty of being medically incompetent? __ Yes __No 7. Have you ever been a defendant in any malpractice matter that resulted in a settlement or judgment? __ Yes __No 8. Do you have any medical condition that in any way impairs or limits your ability to practice medicine? __ Yes __No 9. Do you currently have a complaint or open investigation in which you are involved? The Criminal Justice Information Report received by the Board from the United States Department of Justice Federal Bureau of investigation is inclusive of all arrests including juvenile arrests even when records are expunged by a court of law. In a written supplemental statement to the Board, an applicant is required to list all arrests, pleas and convictions, jail or prison time served and any probation served. Failure to provide complete information for questions answered Yes on this page may require the applicant to appear before the Board for a personal interview. ____No ___ Yes I submitted a written supplement to this application for the above questions. Subscribed And Sworn To Before A Notary Public: State of________________________________________________) County of______________________________________________) Print The Applicants Full Name: ___________________________________________________________________________ being first duly sworn upon his or her oath deposes and says all of the following: I am the person named in this application. I have read and understand the contents of this application. The information contained in this application is true and correct to the best of my ability and the information submitted is without fraud, deceit or misrepresentation. I hereby authorize any hospital, institution, organization, personal physician, past or present employer, past or present business or professional associate or any local, state, federal or foreign governmental agency to release any information to the State of Arizona in connection with my application and state that a photocopy of this authorization shall have the same effect as the original. I also authorize the State of Arizona Naturopathic Physicians Board of Medical Examiners, or its successor, to release any information submitted by me, upon request, to the public or to any licensing agency, or to any other person, when such request is required or permitted by Arizona Revised Statutes. I acknowledge that any falsification in my application is cause to deny my application or for the Naturopathic Physicians Board of Medical Examiners to hold a hearing to revoke any naturopathic medical student internship, preceptorship or preceptorship training registration that is issued to me by the Board. I authorize the Board to tape record any application interview that is conducted of myself in regards to this application. Signature of Applicant: _______________________________________________________________________________________ Subscribed and sworn to before me this ______ day of _____________________, 20________ (OFFICIAL STAMP) _______________________________________________________ Notary Public Signature Revised 2/2015 State of Arizona Naturopathic Physicians Medical Board Protecting the Publics Health Phone: (602) 542-8242 FAX (602) 542-3093 Email: Info@aznd.gov VERIFICATION REQUEST FORM Notice to Applicant: You are required to send this form to each statutorily appointed licensing agency or board that issued or refused to issue you a professional or occupational license or certificate in the practice of medicine or in any healing art. It is your responsibility to correctly identify yourself to that agency or board and pay them a fee, if any, for remitting the information to the State of Arizona. Applicant Name: ________________________________________________________________________ Last First Middle Applicant License, Registration or Certificate Number: _________________________________SS# _______/ _______/_______ I hereby authorize you to send directly to the state of Arizona the information requested herein Signature______________________________________________________Date_____________________ Following Information to be Completed by the Licensing Agency or Board Verification of License, Registration or Certificate Is the person named above licensed, registered or certified by your Agency or Board? % yes % no Name of the individual as it appears on the license, registration or certificate: _______________________________________________________________________________________ Check all that apply; % license % registration % certificate License, registration or certificate number _____________________ Initial date issued_________________ __ Yes __No . Is the license, registration or certificate active If No, attach the information to this document __ Yes __No . Is an action pending or has any action been taking against the applicant? 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