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.
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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 are not dispensing and plan not to renew your Certificate to Dispense, let us know within 10 days in writing include the reason and date, you can send an email to [email protected]  Certificate to Dispense Application, CTD Renewal Application |
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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 |
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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 |
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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. Preceptorship Engage Application, Preceptorship Engage Renewal |
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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 |
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Medical License Reinstatement Revised 1/18/2017 Read the application for reinstating prior to applying Reinstatement of Medical License Application |
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Naturopathic Medical License/License Renewal Please review Medical License application prior to applying, you will apply based on exam or endorsement. Medical License Application, Annual Renewal Application |
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Specialist Certificate Specialist Certificate shall meet the requirements of A.R.S. Title 32 Chapter 14. Specialist Certificate |
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Address/Name Change This is a fillable form, you will complete the changes then print.You can send in an email, fax or U.S. mail. You can just email your address change to [email protected] can use ONLINE PAYMENT to add or change an address also. |
Address/Name Change (fillable form) |
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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. |
License Verification Request |
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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 |
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Retire/Cancellation Request Form Use the form if you would to retire your Naturopathic License or Cancel a Certificate.You can email, or fax the request FAX # 602/542/3093 |
Retire/Cancellation Request Form |
