Fillable TEACHING LICENSE APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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TEACHING LICENSE APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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The TEACHING LICENSE APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery) form is 21 pages long and contains:

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  • 20 check-boxes
  • 182 other fields

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

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01/2018 Page 1
TEACHING LICENSE APPLICATION
Fee: $318.00
THIS AREA FOR OFFICIAL USE ONLY
A person who holds a teaching license shall not open an office or designate a place to meet patients or receive calls relating to the
practice of osteopathic medicine in this state outside of the facilities and programs of the approved school or teaching hospital.
PLEASE COMPLETE CAREFULLY
Answer “none” or “N/A” if that is the correct response. Leave no fields blank. In accordance with Arizona Revised Statutes § 32-1831, you may
be required to submit to a personal interview, a physical examination or a mental health evaluation, or any combination of the these at your
own expense in addition to submitting this application and requested documentation.
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: APPLICANT IDENTIFICATION AND CONTACT INFORMATION – REQUIRED
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
__________________________________________________________________________________________________________________________
Attach a photograph
for identification purposes
Approximately
2” x 2”
TAKEN WITHIN THE
PAST SIXTY (60) DAYS
DO NOT STAPLE PHOTO
Transparent tape at edges
is preferred
________________________________________ _________________________________________ _______________________________
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.
__________________________________________________________________ ___________________________________________
Mailing Address Cell/Daytime Phone Number
__________________________________________________________________ Gender: Male Female
City State Zip
__________________________________________________________________ Check if using FCVS
Email Address
Date of Birth: ___________________________ Social Security Number: _________________________________
01/2018 Page 2
SECTION 2: ALTERNATE CONTACT INFORMATION 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.
SECTION 3: MEDICAL EDUCATION Please submit Form No. 1 to the Osteopathic College from which you graduated.
The form must be completed by the school Registrar or Dean and returned DIRECTLY to the Arizona Osteopathic
Board in order to provide verification of your education.
Name of College or School of Osteopathic Medicine
Graduation Date (M/D/YYYY)
SECTION 4: POSTGRADUATE TRAINING Please fill in areas completely and accurately. Please submit Form No. 2 to
each postgraduate training facility/program at which you trained. The form must be completed by the Program
Director and returned DIRECTLY to the Arizona Osteopathic Board in order to provide verification of your training. If
the facilities or programs are now defunct, please so indicate. If more space is needed, use a separate sheet.
Type of
Program
Name of Institution or Program
City/State
Specialty
Dates Attended
Start (M/D/YYYY) End (M/D/YYYY)
PGY-1
Residency
Residency
Residency
Fellowship
Fellowship
SECTION 5: EXAMINATIONS Please list the national medical licensure examinations you passed and the dates you
passed (This may have been FLEX, COMLEX, USMLE, NBOME, etc. Please do not list your specialty board certification
exams.
Name of Exam / Part or Level
Date Passed
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.
01/2018 Page 3
SECTION 6: PRIMARY FIELD OF PRACTICE / BOARD CERTIFICATION OF SPECIALITIES Please list your primary field of
practice. If you are currently completing PGT, list the field in which you are training. If you are Board certified in a
specialty by either AOA-BOS or a specialty board of ABMS, list those. Please write either AOA-BOS or ABMS to indicate
by which Board you are certified. The Arizona Osteopathic Board does not recognize specialty certifications by other
credentialing bodies. Attach a copy of each certification listed.
Primary Specialty/Field of Practice: _________________________________________________________________
ABMS / AOA Board Specialty
Attach additional sheet if needed
Date Certified
Expiration Date
SECTION 7: 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. A
verification of license must be submitted from each state in which you were granted a license, regardless of the status of
the license. This verification must include a current status and disciplinary history, if any.
Issuing State
License Number
Date of
Issuance
Date of
Expiration
License Status
SECTION 8: PRACTICE EXPERIENCE Provide a list of all health care facilities, clinics, urgent cares, offices, etc., at which
you have practiced medicine, consulted medicine or had staff privileges, whether employed or in private practice. This
list must account for all years since initial licensure. This does not include facilities at which you were doing PGT
rotations. If more space is needed, please use a separate blank sheet of paper. If this information is in your CV, you
may write “see CV” in the table and include your CV with your application instead.
Verification of the last seven (7) years of practice experience is required. Please send Form 3: Practice Experience
Verification to the appropriate entities in order to obtain this, and then have the completed form(s) sent directly to the
Board in order to maintain the integrity of the verification. We accept verifications by fax, email or mail from the
verifying entities only.
Start Date
(M/D/YYYY)
End Date
(M/D/YYYY)
Name of Health Care Facility or Employer
City/State
SECTION 9: ATTESTATION Please read the following statements for (a) and (b) and attest your understanding by
initialing on the line provided. Please fill in the information requested in (c).
a) _________ A person who is licensed pursuant to A.R.S. § 32-1831 shall not open an office or designate a place to meet
patients or receive calls relating to the practice of osteopathic medicine in this state outside of the facilities and programs
of the approved school or teaching hospital.
b) _________ A person who is licensed pursuant to A.R.S. § 32-1831 is subject to the disciplinary provisions pursuant to this
chapter.
c) I will be employed as a full-time faculty member to provide professional education through lectures, clinics or
demonstrations for the following accredited school or program: _______________________________________________
Accreditation number: ________________, for a period beginning _______________ and ending __________________.
01/2018 Page 4
SECTION 10: PROFESSIONAL CONDUCT HISTORY
Failure to properly answer the questions below may result in Board disciplinary action including revocation or denial of license.
SECTION 11: PROFESSIONAL CONDUCT HISTORY - CONFIDENTIAL QUESTIONNAIRE
SECTION 12: 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 teaching 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: _______________________________________
SEAL
My commission expires: ______________________________
If you answer “yes” to any of the following questions, please attach an explanation of the situation on a separate
blank sheet of paper. As appropriate, attach copies of documents from hospitals, programs, State Boards, courts
and law enforcement agencies confirming your explanation.
YES
NO
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 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 resolved?
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?
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.
YES
NO
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.
01/2018 Page 5
ARIZONA STATEMENT OF CITIZENSHIP
AND ALIEN STATUS FOR STATE PUBLIC BENEFITS
Teaching License
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 LICENSE/PERMIT (Check one) LICENSE PGT PERMIT LOCUM TENENS TEACHING
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 Page 6
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
Completed two-page form may be faxed to Board office at 480-657-7715
click to sign
signature
click to edit
01/2018 Page 7
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. 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. If proof of legal status does not include a photo, a copy of a current government issued
photo ID such as a driver’s license or US passport is required.
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)
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.
01/2018 Page 8
Fingerprinting Required
(A.R.S. § 32-1822(A)(9))
Effective September 1, 2017, fingerprinting is required for the following applications:
Initial (New) License
Teaching License
Locum Tenens Registration
All applicants will receive a packet from the Board that will detail the steps the applicant must take to
comply with the fingerprint process. Please note that the fingerprint card is specific and pre-printed for
this Board; therefore, the applicant must use the fingerprint card provided by the Board or fingerprint
card FD-258 to include the same pre-printed information within each blue box.
The fingerprint technician is required to fill out and date the identity verification form, place the identity
verification form and the completed fingerprint card into the envelope, and seal the envelope closed.
Once the envelope is sealed, the technician will return the envelope to the applicant. They applicant
must mail or deliver the sealed envelope to the Board office.
Failure to return the sealed envelope with the fingerprint card and identity verification form enclosed
will result in a delay in processing your application. If you have further questions, please review the
Fingerprinting FAQ on the website.
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
__________________________________________________________________________________________________________________________________________________________
01/2018 Page 9
Form No. 1: MEDICAL EDUCATION VERIFICATION
To Registrar: In applying for a teaching license in Arizona, the Arizona Board of Osteopathic Examiners requires this form be
completed by the Dean or the Registrar of the osteopathic medical school from which I graduated. My signature below is
authorization to release any information in your files of record, favorable or otherwise, DIRECTLY to the ARIZONA BOARD OF
OSTEOPATHIC EXAMINERS, 1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007.
Applicant Name: _________________________________________________________, D.O. Last 4 digits of SSN: ______________
Signature _____________________________________________________ Date (Month/Day/Year)__________________________
_____________________________________________________________________________
THIS SECTION TO BE COMPLETED BY AN OFFICIAL OF THE OSTEOPATHIC MEDICAL SCHOOL
This certifies that __________________________________________________________________________ , D.O.
(Name of Applicant)
was enrolled in: ___________________________________________________________________________________________
(Name of Osteopathic College of Medicine)
__________________________________________________________________________________________
(Location – City/State)
The undersigned further certifies that the records of this institution show that the applicant was granted an Osteopathic Medical
Degree by the above named COM on: _____________________________ Date (Month/Day/Year)
COMMENTS: ________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Signature: ______________________________________________________________________________ Date: ______________________________________
Name Typed or Printed: _____________________________________________________ Title: _____________________________________________________
Address: __________________________________________________________________________ Phone No.: ______________________________________
City/State/Zip: _________________________________________________________________ Fax No.: ___________________________________
Contact person, if different than above: ___________________________________________________________________________________________
Email: _____________________________________________________________________________________________________________________
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Completed form may be faxed with coversheet to Board office at 480-657-7715
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
___________________________________________________________________________________________________________________________
click to sign
signature
click to edit
01/2018 Page 10
Form No. 2: POSTGRADUATE TRAINING VERIFICATION
To Program Director: In applying for a teaching license in Arizona, the Arizona Board of Osteopathic Examiners requires this form be completed by the Program
Director. My signature below is authorization to release any information about me in your PGT program’s files of record, favorable or otherwise DIRECTLY to the
Arizona Board of Osteopathic Examiners in Medicine and Surgery.
Applicant Name: ___________________________________________________________________________________________, D.O.
Signature _____________________________________________________________________ Date (Month/Day/Year) ___________________________________
THIS SECTION TO BE COMPLETED BY PROGRAM DIRECTOR
FOR PGT PROGRAM DIRECTOR: The above named individual has applied for licensure in Arizona and has stated that he/she has participated in a PGT program at
your facility. He/she is required to submit this form to you for completion. Therefore, please complete this form and return it to our office at the address above.
1. Important – Program Participation: Please report internships, residencies and fellowships separately. Please report incomplete postgraduate years (PGY)
separately from those successfully completed. If the postgraduate year is currently in progress, report the expected completion date in the “To” field.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
From: __________/__________/_________ To:__________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY: __________________________________________________________________________________
From: __________/__________/_________ To: __________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PG Year(s):_______________ DEPARTMENT/SPECIALTY:__________________________________________________________________________________
From: __________/__________/_________ To: __________/__________/_________
Successfully completed? Yes No In Progress
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2. The following questions apply to the PGT years stated above. Please check the appropriate response.
a. This program was approved for postgraduate training during this individual’s attendance by: AOA ACGME DUAL
b. Did this individual ever take a leave of absence or deferment/break from his/her training? Yes No
c. Was this individual disciplined and/or placed under investigation or on probation? Yes No
d. Did this individual participate in a confidential or public diversion program for substance abuse monitoring? Yes No
Please explain below any “Yes” response(s) to the questions above. Use a separate blank sheet of paper if more room is necessary.
3. COMMENTS: ________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Signature: ______________________________________________________________________________ Date: __________________________________________
Name Typed or Printed: ___________________________________________________________________ Title: __________________________________________
Full name of Program or Hospital: __________________________________________________________________________________________________________
Address: ________________________________________________________________________ Phone No.: ____________________________________________
City/State/Zip: ___________________________________________________________________ Fax No.: ____________________________________________
Contact person, if different from above: ______________________________________________ Email: ________________________________________________
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
___________________________________________________________________________________________________________________________
Internship
Residency
Fellowship
Internship
Residency
Fellowship
Internship
Residency
Fellowship
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Completed form may be faxed with coversheet to Board office at 480-657-7715
01/2018 Page 11
Form No. 3: PRACTICE EXPERIENCE VERIFICATION
In applying for a teaching license in Arizona, the Arizona Board of Osteopathic Examiners requires this form be completed by the Medical
Employer/Director where I have practiced medicine for evaluation of my professional record and mental and physical capabilities during the seven (7)
years preceding my application. This is authorization to release any information in your files of record DIRECTLY to the Arizona Board of Osteopathic
Examiners, 1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Applicant Name: ______________________________________________________________________________________, D.O.
Signature ____________________________________________________________ Date (Month/Day/Year) _________________________
_____________________________________________________________________________
THIS SECTION TO BE COMPLETED BY FACILITY OFFICIAL
1. This is to certify that __________________________________________________________________________________________, D.O.,
held/holds the following position: _____________________________________________________________________________________
Dates: From: _________________________________________ To: _________________________________________
Month/Day/Year Month/Day/Year
Circle the correct response to the questions below: (“Yes” responses require written explanation.)
2. Has this individual participated in a confidential or public diversion program for substance abuse monitoring? Yes No
3. Was this individual disciplined and/or placed under investigation or on probation? Yes No
Please explain below any “Yes” response(s) to the two questions above.
Use a separate blank sheet of paper if more room is necessary.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Practice/Facility: _______________________________________________________ Phone No: ___________________________________
Address: _________________________________________________________ Fax No.: ____________________________________
City/State/Zip: _________________________________________________________ Email: ______________________________________
Name of Official (printed): _______________________________________________ Title: _______________________________________
Signature: ___________________________________________________________________ Date: ______________________________
.
TO MAINTAIN INTEGRITY OF THE VERIFICATION, SEND ORIGINAL DIRECTLY TO THE ARIZONA BOARD OF OSTEOPATHIC EXAMINERS
Completed form may be faxed with coversheet to Board office at 480-657-7715
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
___________________________________________________________________________________________________________________________
01/2018 Page 12
Arizona Board of Osteopathic Examiners Teaching License Application
MALPRACTICE CLAIM / SUIT QUESTIONNAIRE
Complete the information below for each instance of any award, settlement or payment of any kind either 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 Practitioners Data Bank; OR if you have been notified that any such suit or claim is pending. Duplicate this form as
necessary and use as a cover sheet with all supporting documentation required.
1. Applicant’s name: ________________________________________________________________________
2. Name of patient: _________________________________________________________________________
Last name First name Middle name/initial
3. Date of occurrence: ________________________________
4. Location of occurrence: ___________________________________________________________________
Name of hospital / office / clinic) City / State
5. Current status of suit/claim: Pending Settled
If settled, was it settled: in court out of court Date of settlement: ______ /______ /______
6. Total Amount of Settlement / Award $________________ Amount attributable to you $_________________
7. Name of your insurance company: ____________________________________________________________
8. Has this case been investigated or reviewed by any state Licensing Board? No Yes Pending
If Yes or Pending, name of Licensing Board: _____________________________________________________
What was the outcome? Please include a copy of the Licensing Board’s final disposition:
_______________________________________________________________________________
9. On a separate sheet of paper, in your own words, briefly describe the claim / suit and your involvement.
10. Attach the following documents to this form. Your application will not be decided upon until the following
attachments have been received:
a. plaintiff’s complaint or claim to insurer;
b. settlement agreement, court order or dismissal letter (if case has concluded) and
c. Board resolution after investigation of case (if case has concluded).
__________________________________________________________ __________________________
Signature of applicant Date signed
Completed form and documentation may be faxed to Board office at 480-657-7715
01/2018 Page 13
CERTIFICATION OF TEACHING LOCATION
TO BE COMPLETED BY THE COLLEGE OF OSTEOPATHIC MEDICINE AND/OR THE TEACHING HOSPITAL'S
ACCREDITED GRADUATE MEDICAL EDUCATION PROGRAM IN THE STATE OF ARIZONA
This is to certify that ________________________________________________________________
(Name of Osteopathic Physician)
will be employed as a full-time faculty member to provide professional education through lectures, clinics or
demonstrations for the following accredited school or program:
_____________________________________________ Accreditation number: __________________
for a period beginning_____________________ and ending on_____________________.
(mm/dd/yyyy) (mm/dd/yyyy)
Signature of Dean/Director _______________________________________________________________
Typed/Printed Name of Dean/Director ______________________________________________________
College/School/Teaching Hospital Name: ____________________________________________________
College/School/Teaching Hospital Address: ___________________________________________________
College/School/Teaching Hospital City, State, Zip: ______________________________________________
Phone Number:_______________________________ Fax Number:_______________________________
College/School/Hospital Seal
(If no seal, please indicate)
01/2018 Page 14
Teaching License Application Checklist
Teaching License Application packets with original notarized signatures must be mailed or delivered to the Board office.
Scanned or faxed license applications are not acceptable.
A. Before you send us your application packet, please make certain you have completed the following.
1.
A current version of the Board’s teaching license application. Visit www.azdo.gov>For DOs> New License Application.
2.
All sections of the four page application or marked N/A if not applicable.
3.
A clear passport type color picture of you (2” x 2”) taken within the past 60 days attached to the front page of the
application. We prefer you use transparent tape around the edges because your application packet will be scanned.
4.
Your name, date and notarized signature in Section 12 of the application. DO NOT LEAVE ANY QUESTION UNANSWERED
IN THE APPLICATION OR ANY FIELD IN THE ATTESTATION AND NOTARIAL CERTIFICATE BLANK.
5.
Photocopy of a current valid government issued photo ID. For example, a driver’s license, U.S. Passport or military ID.
6.
Copy of court records of any name changes, if applicable.
7.
Explanations and supporting documentation of all “yes” answers to Professional Conduct History. This includes medical
malpractice settlements, etc. Use the form “Malpractice Claim/Suit Questionnaire” as a coversheet for each instance of
medical malpractice.
8.
Copy of AOA-BOS or ABMS specialty certification or letter verifying specialty and/or subspecialty, dates of issuance and
expiration, if applicable.
9.
Completed Citizenship/Alien status two page form signed in section IV.
10.
Photocopy of current U.S. passport, birth certificate or a legible copy of one or more document(s) from the "Evidence of
U.S. Citizenship, U.S. National Status or Alien Status" page included in this packet.
11.
Copy of your osteopathic diploma.
12.
Copies of your PGT certificates.
13.
$318 application fee. The fee can be paid by Visa, MasterCard, American Express, check or money order. This fee is for
processing the application only and is non-refundable.
B. It is your responsibility to make certain the following verifications are sent directly to the Board.
14.
Verification of graduation from college/school of osteopathic medicine (Form 1).
15.
Verification of all postgraduate training, regardless of completion (Form 2).
16.
Verification of state licensure and professional conduct history, if applicable. Each state has its own form and may
require payment of a fee.
17.
Verification of practice experience (Form 3). This is for each facility at which you practiced medicine or for whom you
practiced medicine in the last seven (7) years.
18.
Certification of Teaching Location form.
C. Fingerprint Packet – You will be sent a fingerprint packet after your application has been received by the Board.
19.
Applicants for a Teaching License are required to undergo a background check. Follow the instructions in the fingerprint
packet. Fingerprint cards cannot be accepted prior to the application. No fingerprint fee is required at this time.
Please do not include this checklist with your application. Its purpose is to help you complete the paperwork associated with
licensure and submit a satisfactory application which will prevent any unnecessary delays.
Please call or email with any questions
480-657-7703 OR Questions@AZDO.gov
01/2018 Page 15
CREDIT CARD PAYMENT AUTHORIZATION FOR OSTEOPATHIC TEACHING LICENSE APPLICATION FEE
Name of Applicant: _______________________________________________________________________, D.O.
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
_____________________________________________________________________________________________________________________________________________________
Please complete and return this form and mail with your application if paying by credit card.
Amount: $318.00
Type of Card: Visa MasterCard American Express
Visa or MasterCard #: _______________ - _______________ - _______________ - _______________
OR
American Express #: _______________ - _________________________ - _________________
Expiration Date: ___________ / ___________ (MM/YY)
Name as Shown on Payment Card: ___________________________________________________________________
Billing Address: (Required)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: _________ Zip: _________________
Phone Number of Card Holder: (Required) _______________________________________________________
Mailing Address (Required if different from billing address)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: _________ Zip: _________________
Phone Number of Card Holder: (Required) _______________________________________________________
Signature of Cardholder: ___________________________________________________ Date: _____________________
Note: The Board shreds this form after payment has been authorized by your credit card company
01/2018 Page 16
Teaching License Application Processing Overview
YOU HAVE SUBMITTED YOUR APPLICATION, WHAT HAPPENS NEXT?
EMAIL ACKNOWLEDGEMENT: When Board staff has received your application packet, you will be sent an email
acknowledging receipt. If you do not provide an email address, no acknowledgement will be sent. This
acknowledgement does not mean that all required documents have been received.
FINGERPRINT PACKET: As of September 1, 2017, teaching license applicants are required to undergo fingerprinting
per A.R.S. § 32-1831 and § 32-1822(A)(9). A fingerprint packet will be sent to you at the mailing address you provided
on your application. Follow the instructions in the fingerprint packet to avoid delays or having to repeat submission
of your fingerprints. Your application will remain administratively incomplete until the fingerprint processing is
complete.
ADMINISTRATIVE COMPLETENESS/DEFICIENCY LETTER: Within 30 days after sending the acknowledgement email,
staff will mail a letter to you listing the missing or incomplete information needed to complete your application.
If all the documents in both A and B of the checklist have been received, you will not receive this letter.
ADMINISTRATIVELY COMPLETE: After everything in the checklist has been received, the Board staff will
independently obtain the following:
1. National Practitioner Data Bank report
2. Federation of State Medical Board’s Practitioner Profile
At this point your application is administratively complete and moves to substantive review.
SUBSTANTIVE REVIEW: This stage of the application process is the evaluation of all answers, documents and
verifications collected and the decision whether they demonstrate you are qualified for a teaching license in Arizona.
You may be required to appear before the Board at a regularly scheduled Board meeting for a decision on your
application.
ISSUANCE OF LICENSE: If at the conclusion of the substantive review your application is approved, you will receive an
issuance letter which will provide your teaching license number, issuance date and expiration date. Please keep this
letter for your records. It will be your proof that you hold a teaching license in Arizona.
MAINTAINING YOUR LICENSE: Your initial teaching license will be valid for two years from the date it is issued. If
you intend to continue teaching, you will need to re-apply for your Teaching License at least 60 days prior to the
expiration date. CME is required to maintain your Teaching License. Please see the Teaching License FAQ on our
website at www.azdo.gov for more information regarding maintaining and re-applying for your teaching license.
Arizona Revised Statutes and Rules for osteopathic licensure can be found on our website at www.azdo.gov > Statute
and Rules. As a licensed physician you will be subject to all state and local laws and regulations pertaining to public
health and subject to all the same duties and obligations and authorized to exercise all the same rights and privileges
possessed by physicians and surgeons of other complete schools of medicine in the practice of their profession per
A.R.S. § 32-1852.
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TEACHING LICENSE APPLICATION (Arizona Board of Osteopathic Examiners in Medicine and Surgery)

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Completed 20 July 2020

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