Fillable PHYSICIAN ASSISTANT CME EXTENSION REQUEST (Arizona Regulatory Board of Physician Assistants)

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PHYSICIAN ASSISTANT CME EXTENSION REQUEST (Arizona Regulatory Board of Physician Assistants)

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T:\Licensing\New License Applications and forms\New License Application\PA Application\PA CME Extension Request\Revised.01.03.2018
PHYSICIAN ASSISTANT CME EXTENSION REQUEST
A.A.C. § R4-17-205: A licensee who is unable to complete the required hours of continuing medical education for any of the reasons in A.R.S.
§ 32-2523(E) may submit a written request to the Board for an extension no later than 30 days before expiration of the license that contains;
1. The name, address, and telephone number of the licensee;
2. The number of continuing medical education hours completed during the biennial license period;
3. The dates on which the remaining hours of continuing medical education are scheduled to be completed; and
4. Reason for the request;
5. The signature of the licensee.
Reason for
the request:
Last Name:
Middle Name:
1. First Name:
City:
Phone Mobile:
Zip:State: Home Address:
2. CME hours completed during the biennial license period:
3. Date scheduled to complete remaining hours of CME:
5. Signature of Licensee: Date:
License Number:
4.
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PHYSICIAN ASSISTANT CME EXTENSION REQUEST (Arizona Regulatory Board of Physician Assistants)

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Completed 20 July 2020

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