Fillable OSTEOPATHIC MEDICINE & SURGERY APPLICATION FOR PRO BONO (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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OSTEOPATHIC MEDICINE & SURGERY APPLICATION FOR PRO BONO (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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BROWSE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS IN MEDICINE AND SURGERY (AZ) FORMS

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01/2018
1
OSTEOPATHIC MEDICINE & SURGERY
APPLICATION FOR PRO BONO REGISTRATION
The Board may issue a Pro Bono Registration to allow a doctor of osteopathy who is not a licensee to practice in this state
for a total of sixty (60) days each calendar year if the doctor meets the requirements in accordance with A.R.S. § 32-1833.
Please follow instructions when filling out the application. Answer “none” or “N/A” if that is the correct response. Leave no fields blank.
In accordance with A.R.S. § 41-1030 The Board is required to notify you of the following:
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by
statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing
requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or
condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney
fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this
section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal
pursuant to the Agency's adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
SECTION 1: CONTACT INFORMATION
APPLICANT IDENTIFICATION: Include a current government-issued picture I.D.
________________________________________ _________________________________________ _______________________________
Last Name First Name Middle Name
______________________________________________________________________________________________
Other Names Used: (Provide copies of marriage license or court records). If this does not apply to you, write N/A.
ARIZONA CHARITABLE ORGANIZATION FOR WHICH YOU WILL BE PROVIDING SERVICES: (Required): Provide the facility name,
address and contact information for this location in Arizona.
__________________________________________________________________ ___________________________________________
Practice/Facility Name Practice/Facility Phone Number
__________________________________________________________________________________________________________________
Practice/Facility Address
__________________________________________________________________________________________________________________
City State Zip
CONFIDENTIAL INFORMATION (Required): Your residential address will remain confidential if a practice address is on file. If you do
not provide a practice address, your residential address will default to your public address of record. Email address, Date of Birth and
SSN are always confidential.
__________________________________________________________________ ___________________________________________
Residential Address Cell/Daytime Phone Number
__________________________________________________________________ __________________________________________
City State Zip Email Address
Date of Birth: _________________ Social Security Number: _________________
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | Fx: 480-657-7715 | www.azdo.gov | questions@azdo.gov
________________________________________________________________________________________________________________________________________
Mailing Address (Check One): Selection of a mailing address indicates where you would like to receive Board mailings.
Practice Address Residential Address
01/2018
2
SEAL
SECTION 2: ALTERNATE CONTACT: You may authorize someone else to check the status of your application by providing the following
information and signing below. If this section is blank, only you, the applicant, will be told the status of this application.
Name of Contact: ______________________________________________ Phone Number: ____________________________
Name of Company: _________________________________________ Email: _________________________________________
Address/City/State/Zip: ____________________________________________________________________________________
I, _________________________________________________, give authorization for the above named person to be informed of
the status of my application for licensure in Arizona.
SECTION 3: OTHER STATE LICENSES: Please fill in the information for each license you hold or have held. If you have more than fits in the
table below, please use a separate blank sheet of paper for the ‘overflow’ information. If you were previously licensed in Arizona, list that also. On
a separate sheet of paper explain any time you were not licensed. You must submit a verification of licensure from each state in which you were
granted a license. This verification must include a current status and disciplinary history, if any.
Issuing State
License Number
Date of Issuance
Date of Expiration
SECTION 4: PROFESSIONAL HISTORY: Please provide the name of the COM from which you graduated and the year of graduation. On the next
line, please provide your specialty/area of interest. This information is required for the National Practitioner Data Bank report.
COM Name: Year:
Specialty/Area of Interest:
SECTION 5: ATTESTATIONS
I agree to render all medical services without accepting a fee or salary or perform only initial or follow-up examinations at
no cost to the patient and the patient’s family through a charitable organization.
I am not the subject of an unresolved complaint in any state, territory or possession of the United States.
I have never had a license revoked or suspended by a health professional regulatory board of another jurisdiction.
I will practice in Arizona no more than 60 days each calendar year under this registration.
SECTION 6: OATH and NOTARIZATION TO BE SIGNED BY APPLICANT AND NOTARIZED
____________________________________________, 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: ______________________________
01/2018
3
ARIZONA STATEMENT OF CITIZENSHIP
AND ALIEN STATUS FOR STATE PUBLIC BENEFITS
Professional License and Permit
Arizona Board of Osteopathic Examiners in Medicine & Surgery
Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. § 1621, provides
that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-exempt "qualified aliens" (and
sometimes only particular categories of qualified aliens), nonimmigrants, and certain aliens paroled into the United States are
eligible to receive state or local public benefits. With certain exceptions, a professional license and commercial license issued by a
State agency is a State public benefit.
Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must submit documentation to the
license agency that satisfactorily demonstrates the applicant’s presence in the United States is authorized under federal law.
Directions: All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals must also
complete Section III.
Submit this completed form and a copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S.
National Status or Alien Status" with your application for license or renewal. If the document you submit does not contain a
photograph, you must also provide a government issued document that contains your photograph. You must submit supporting
legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your current legal name.
SECTION I – APPLICANT INFORMATION
APPLICANT'S NAME (Print or type) _____________________________________________________
TYPE OF APPLICATION (Check one) INITIAL APPLICATION RENEWAL
TYPE OF LICENSE/PERMIT (Check one) DO Pro Bono Registration
SECTION II – CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a citizen or national of the United States? Yes No
If Yes, indicate place of birth:
City ______________________________ State (or equivalent) _________ Country or Territory _______________________
If you answered Yes, 1) Attach a legible copy of one or more document(s) from the attached
"Evidence of U.S. Citizenship, U.S. National Status or Alien Status" page.
Name of document ___________________________________________
2) Go to Section IV.
If you answered No, you must complete Section III and IV.
SECTION III – ALIEN STATUS DECLARATION
To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropriate box. Attach a legible copy of one or more document(s) from the attached "Evidence of U.S. Citizenship, U.S. National
Status or Alien Status". Name of document provided _____________________________________________________________.
01/2018
4
Qualified Alien Status (8 U.S.C. §§ 1621(a)(1),-1641(b) and (c))
1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
2. An alien who is granted asylum under Section 208 of the INA.
3. A refugee admitted to the United States under Section 207 of the INA.
4. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.
5. An alien whose deportation is being withheld under Section 243(h) of the INA.
6. An alien granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980.
7. An alien who is a Cuban/Haitian entrant.
8. An alien who has or whose child or child's parent is a "battered alien" or an alien subject to extreme cruelty in the
United States.
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.C § 1101 et seq.] Nonimmigrants are persons who
have temporary status for a specific purpose. See 8 U.S.C § 1101(a)(15).
Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA
Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
11. A nonimmigrant whose visa for entry is related to employment in the United States or
12. A citizen of a freely associated state, if section 141 of the applicable compact of free association approved in Public Law
99-239 or 99-658 (or a successor provision) is in effect (Freely Associated States include the Republic of the Marshall
Islands, Republic of Palau and the Federate States of Micronesia, 48 U.S.C. § 1901 et seq.);
13. A foreign national not physically present in the United States.
Otherwise Lawfully Present
14. A person not described in categories 1-13 who is otherwise lawfully present in the United States. PLEASE NOTE: The
federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons who fall into this
category ineligible for licensure. See 8 U.S.C. § 1621(a).
SECTION IV - DECLARATION
All applicants must complete this section.
I declare under penalty of perjury under the laws of the state of Arizona that the answers and evidence I have given are true and
correct to the best of my knowledge.
APPLICANT'S SIGNATURE
TODAY'S DATE
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01/2018
5
EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS OR ALIEN STATUS
You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same as your
current legal name.
Evidence showing authorized presence in the United State includes the following:
1. An Arizona driver license issued after 1996 or an Arizona non-operating identification license.
2. A driver license issued by a state that verifies lawful presence in the United States.
3. A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (on
or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa or the Northern
Mariana Islands (on or after November 4, 1986, Northern Mariana Islands local time). When submitting a birth certificate, a
picture ID is also required.
4. A United States certificate of birth abroad.
5. A United States passport. ***Passport must be signed***
6. A foreign passport with a United States visa.
7. An I-94 form with a photograph.
8. A United States citizenship and immigration services employment authorization document or refugee travel document.
9. A United States certificate of naturalization.
10. A United States certificate of citizenship.
11. A tribal certificate of Indian blood.
12. A tribal or Bureau of Indian Affairs affidavit of birth.
13. Any other license that is issued by the federal government, any other state government, an agency of this state or a political
subdivision of this state that requires proof of citizenship or lawful alien status before issuing the license.
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OSTEOPATHIC MEDICINE & SURGERY APPLICATION FOR PRO BONO (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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Completed 20 July 2020

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