Section 9: Professional Conduct History
Failure to properly answer the questions below may result in Board disciplinary action including revocation or denial of license.
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a separate blank sheet of paper. As
appropriate, attach copies of documents from hospitals, programs, State Boards, courts and law enforcement agencies confirming your
1. Have you ever been arrested for, charged with or convicted of any felony, or any misdemeanor? You must answer “yes” even if the
offense occurred outside of Arizona, the case has not yet been adjudicated, you completed a diversion program, you received a
suspended sentence or probation, the convictions were dismissed or set aside, your sentence was commuted, the records were expunged,
your civil rights were restored or you received a pardon.
disciplinary or adverse action imposed against any professional license, or were you denied a professional license, or
have you entered into any consent agreement, stipulated order, or settlement with any regulatory board; OR have you been notified of
any complaints or investigations against your license that have not yet been resolved?
3. Has your DEA permit or prescription permit issued by any regulatory board been denied, restricted, suspended, lost, or had any other
adverse action taken against it, OR have you been notified of any complaints or investigations against your authority to prescribe that
have not yet been resolved?
4. Has any award, settlement, or payment of any kind been made by you or on your behalf to resolve a civil suit or malpractice claim
involving your practice even if it was not required to be reported to the National Practitioner Data Bank; OR have you been notified that
any such suit or claim is pending?
5. Have your hospital privileges or health care program affiliations been denied, restricted, lost, suspended or modified, or subjected to any
other adverse action even if that action was not required to be reported to the National Practitioner Data Bank; OR have you been
notified of any complaints against or reviews of your privileges or affiliations that have not yet been resolved?
6. During an internship, residency or fellowship program were you placed on probation, had your privileges restricted or suspended,
terminated from the program or had any other adverse action taken against your participation even if that action was not required to be
reported to the National Practitioner Data Bank?
Section 10: Confidential Questions
If you answer “yes” to either of the following questions, you must submit a detailed written narrative statement concerning matter(s)
including the name of the healthcare providers and treatment centers where you were treated along with the discharge summary of your
treatment and progress. If you are currently participating or have participated in a confidential agreement or order in a program for the
treatment and rehabilitation of doctors of osteopathic medicine impaired by alcohol, drug abuse or for other issues, please submit a copy
of the agreement/order along with compliance reports from the state monitoring programs.
recently been notified, diagnosed with or made aware of any initial or worsening symptoms of a current
may impair or limit your ability to safely practice medicine?
2. Have you entered into a diversion program for evaluation, treatment or monitoring for substance abuse or dependency or for correction
of communication or boundary issues, in lieu of or as a condition of resolving a matter before a regulatory board, criminal or civil
court; OR have you been notified that such action is pending? You must answer “yes” even if you received a pardon, the convictions
were set aside, the records were expunged, your civil rights were restored and whether or not the sentence was imposed or suspended.
Section 11: Declarations & Attestation
a. I hereby give my permission for the Arizona Board of Osteopathic Examiners to secure additional information concerning me or any of the statements in this application
from any person or any source the Board may desire.
b. I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Arizona Board of Osteopathic
Examiners any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection
with processing my application for chiropractic licensure.
c. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or
furnishing of any such information.
d. I further authorize the Arizona Board of Osteopathic
Examiners to disclose to the aforementioned organizations, persons, and institutions any information which is material
to my application, and I hereby specifically release the Board from any and all liability in connection with such disclosure.
e. I further agree to submit to questioning by the Board or any member thereof, and to substantiate my statements if desired by the Board.
f. I will notify the Board in writing within 10 working days if charged with a misdemeanor involving conduct that may affect patient safety or a felony while I am an
applicant for licensure pursuant to A.R.S. § 32-3208 (B).
g. I will notify the Board in writing immediately if I become the subject of an investigation or disciplinary action by any licensing Board.
h. I certify that I have read and personally answered all the questions on this application.
i. I certify that the photograph I have included with this application is a true and correct likeness of me.
j. I understand these fees are non-refundable.
I, the applicant herein, swear or affirm that I have read the statements listed under the Declarations and agree to same, state and depose that all facts, statements, and answers
contained in this application are true and correct. I am not omitting any information that may be of value to the Board of Osteopathic Examiners in determining my
qualifications, whether it is called for or not. I agree that any falsification, omission, or withholding of information or facts concerning my qualific
ations as an applicant shall
be sufficient to bar me from licensure. Such falsification, omission, or withholding shall serve as sufficient grounds for the revocation or suspension of my license, if
discovered after issuance of the license. A.R.S. § 32-1800 et seq., Arizona Osteopathic Medicine Act.
e of _____________________)
nty of _______________________)
Subscribed and sworn before me this
____ day of ____________________, 20 .
My Commission Expires:________________________________