Forms
FOLLOWING IS A LIST OF FORMS, LICENSE APPLICATIONS & RENEWALS.
32-3801 . PERSONAL INFORMATION MAINTAINED BY THE PROFESSIONAL BOARDS; CONFIDENTIALITY
Notwithstanding any law to the contrary, a professional's residential address and residential telephone number or numbers maintained by a professional board established pursuant to this title are not available to the public unless they are the only address and numbers of record.
RENEWALS:
- Reminders are sent to our licensees and certificate holders as a courtesy.
- It is the responsibility of the licensee or certificate holder to renew in a timely manner.
- To avoid an expired license, or expired certificates, & late fees, renew on time.
- A license or certificate automatically expires if not renewed within sixty days after the due date.
- Licensing
- Request Forms
- A and B List
- Fingerprint Card Submission
- Optional Fee Waiver Form
- Fee Schedule
|
Certificate to Dispense/Renewal Certificate to Dispense Certificate to Dispense means an approval granted by the Board to dispense a natuural substance, drug, or device. Defiinitions R-4-18-901 Qualifications R4-18-902 Be aware that if you do not renew your Certificate to Dispense, you will be subject to pay a renewal and late fee for each year the license has been expired. If you do not use your Certificate to Dispense, you can CANCEL your Certificate to Dispense to avoid extra fees in the future, go to www.aznd.gov then Forms →Request tab.  Certificate to Dispense Application, CTD Renewal Application |
|
Clinical Training Certificate Application/Annual Renewal Application Rely on the Statutes and Rules for requirements to participate in Clinical training. The renewal date is the issue date of the Intial Clinical Certificate. Clinical Training Application, Clinical Training Renewal Application |
|
Conduct Preceptorship Certificate This application is for a Naturopathic Doctor to conduct a preceptorship program this is a initial/renewal application. Preceptorship Training Application/Renewal Application |
|
Engage in Preceptorship Certificate It is the responsiblity of the certifiacate holder to renew in a timely manner. A renewal application must be recieved by or on 7/1/2017 to avoid a late fee. Engage Preceptorship Training, Preceptorship Training Renewal |
|
Medical Assistant Application/Medical Assistant Renewal Read the application and requirements prior to applying for a Medical Assistant Certificate. Medical Assistant Application, Medical Assistant Renewal Application |
|
Medical License Reinstatement Revised 5/22/18 Read the application for reinstating prior to applying Reinstatement of Medical License Application |
|
Naturopathic Medical License/License Renewal Please review Medical License application prior to applying, you will apply based on exam or endorsement. Medical License Application, License Renewal Application |
|
Specialist Certificate Specialist Certificate shall meet the requirements of A.R.S. Title 32 Chapter 14. Specialty Certificate Application |
|
Address/Name Change This is a fillable form, you will complete the changes then print.You can send in an email, or U.S. mail. You can just email your address change to [email protected] You can use ONLINE PAYMENT to add or change an address also. |
Address/Name Change (fillable form) |
|
License Verification Request This is a fillable form to request a written verification of your Arizona Naturopathic Medical license to be sent to another state or agency. The verification will include, issue date, expiration date,also disciplianary actions if any. A $5.00 fee is to accompany the request made payableto AZND Board. |
Verification of your Arizona Medical License |
|
Public Records Request Form This is a fillable form, your will fill out the form, the you will print and sign. You can mail the form with the fee, if there is no fee you can email or fax. |
Public Information Request |
|
Retire/Cancellation Request Form Use the form if you would to retire your Naturopathic License or Cancel a Certificate.You can email, or U.S. mail this document. |
Retire/Cancellation Request Form |
Applicants Requiring Fingerprint Card Submission
11/04/2016
Notice to Applicant: Your fingerprints will be used to check the criminal history records of the FBI If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record. You should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before officials deny you the job, license, or other benefit based on information in the criminal history record. The procedures for obtaining a change, correction, or updating of your FBI criminal history record are set forth in Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.34. Information on how to review and challenge your FBI criminal history record can be found at www.fbi.gov under "Identity History Summary Checks" or by calling (304) 625-5590. To obtain a copy of your Arizona criminal history in order to review/update/correct the record, you can contact the Arizona Department of Public Safety Criminal History Records Unit at (602) 223-2222 to obtain a fingerprint card and a Review and Challenge packet. Information on the review and challenge process can be found on the DPS website (www.dps.gov).
Applications that require Fingerprint Card Submission
Clinical Certificate
Engage in Preceptorship Certificate
Medical Assistant
Reinstatement Application
Intial Medical License Application
