Checklist for an Initial Physician Assistant Universal Recognition License Application
Please do not submit this form with your application. Keep it for your records.
The application fee is $125 payable by check or credit card. The application fee must
be submitted with the application and is non-refundable.
Once your license application is approved, you will be required to pay a prorated
licensure issuance fee up to $370. This fee is prorated based on your birth month.
Provide a complete application, pages 1 - 6. You must complete all questions. If you fail
complete a question, your application will be considered deficient and the processing
your application will be delayed.
EVIDENCE OF LEGAL STATUS
A photocopy of Your Birth Certificate
Applicants must provide a photocopy of a Birth Certificate or Passport.
Proof of Immigration status
A list of the documents that are required to be submitted to the Board is included with
Government Issued Photo ID
A copy of a government issued photo ID is required if the proof of legal status does
not include a photo. Example: driver license or state I.D.
Evidence of legal name change
Applicant must provide evidence of legal name change, if applicable. Example:
Marriage Certificate, court documents showing legal name change.
QUESTIONNAIRE AFFIRMATIVE RESPONSES
Narrative and Supporting Documents
If you answer "yes" to a question on the questionnaire page, please provide the following:
A narrative/explanation of the circumstances that led to the issue disclosed.
Documents to support your narrative. Example: Court documents, Board Orders, etc.
*If documents are not provided, this will delay the application process.
Please note: It is the applicant's responsibility to report to the Board any changes that
may have occurred during the application process. Failure to report any adverse actions
to the Board during the licensure process may result in denial or revocation of your
of established residency in Arizona
or Military Form 2058
• A valid Arizona driver’s license
• A current Arizona motor vehicle registration
• Proof of filing Arizona income taxes in the most recent tax year
• Arizona voter registration
• Documentation of a mortgage for an Arizona residence
• A dated residential rental contract with proof of payment
• Proof of establishment of Arizona utilities
• Proof of enrollment of children in Arizona schools of grades K-12
• Documentation demonstrating a change in permanent address on all pertinent
• Military Form 2058
Public Profile Addendum
Pursuant to A.R.S. § 32-2507(A) The board shall make available to the public a profile of
each licensee. The board shall make this information available through an internet website
and, if requested, in writing.
Information requested to be sent directly to the Board can be sent to the following:
DO NOT EMAIL APPLICATION(S)
Arizona Regulatory Board of Physician Assistants
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664