Arizona Radiation Regulatory Agency
4814 South 40
th
Street
Phoenix, AZ 85040
Telephone: (602) 255-4845 Fax: (602) 437-0705
MEDICAL DIRECTOR
TRAINING AND EXPERIENCE ATTESTATION
1. Name of individual with Professional Title (e.g., MD, DO, NMD or NP).
2. Provide a copy of Arizona Licensing Board certification.
3. Mailing address:
4. Phone number:
5. E-mail address:
6. DIDACTIC/CLASSROOM TRAINING
Board Certification
I attest that I have satisfactorily completed the requirements in R12-1-1438.A.1. and have met all
required by my Arizona Licensing Board and have achieved a level of competency sufficient to
function as a Health Professional for Cosmetic Laser uses in accordance with A.A.C. R12-1-1438.
AND
Training Experience
I attest that I have satisfactorily completed at least 24 hours of Laser Concepts and Laser Safety
didactic training from an ARRA accepted course, as required by R12-1-1438.A.1. and have
attached a copy of my certificate of completion.
OR
I attest that I have satisfactorily completed at least 24 hours of Laser Concepts and Laser Safety
didactic training from either conferences, residency training or laser safety courses prior to October
1, 2010 and have achieved a level of competency sufficient to function as a Health Professional for
Cosmetic Laser uses in accordance with A.A.C. R12-1-1438.
Signature Date
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signature
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