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SECTION 9: PROFESSIONAL CONDUCT HISTORY
Failure to properly answer the questions below may result in Board disciplinary action including revocation of your locum tenens registration.
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a separate blank sheet
. As appropriate, attach copies of documents from hospitals, programs, State Boards, courts and law enforcement
agencies confirming your explanation.
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.
2. Have you had any 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 have 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
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: PROFESSIONAL CONDUCT HISTORY - CONFIDENTIAL QUESTIONNAIRE
SECTION 11: ATTESTATION TO BE SIGNED BY APPLICANT AND NOTARIZED
I attest that all information submitted on or with this application is true. I am the person named on this application. I have read the statutes and
rules regarding licensure and have read the complete application, know the full content thereof, and declare that all of the information contained
herein and evidence or other credentials submitted herewith are true and correct. I am not omitting any information which might be of value to
this Board in determining my qualifications. I acknowledge that any falsification, omission, or withholding of information or facts concerning my
qualifications as an applicant shall be sufficient to deny licensure or constitute grounds to revoke, suspend or cancel the license, if not discovered
until after issuance. A.R.S. §§ 32-1822, -1854(9).
___________________________________________________, D.O. _________________________________
Signature of Applicant Date Signed
State of _______________________ )
County of _______________________ )
On this ______ day of ______________, 20_____ before me personally appeared ______________________________________(applicant), known
to me or whose identity is proved to me by satisfactory evidence to be the person who he/she claims to be and who swore or affirmed before me
that the information in this application is true, complete and correct.
Notary Public: __________________________________________
My commission expires: ______________________________
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.
1. Have you been diagnosed with or developed initial or worsening symptoms of a physical, mental or emotional condition
which did or 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.