Fillable TEMPORARY SPEECH-LANGUAGE PATHOLOGIST INITIAL APPLICATION Bureau of Special (Arizona Department of Health Services)

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TEMPORARY SPEECH-LANGUAGE PATHOLOGIST INITIAL APPLICATION Bureau of Special (Arizona Department of Health Services)

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Revised 05.26.2020 1
TEMPORARY SPEECH-LANGUAGE PATHOLOGIST
INITIAL APPLICATION
Bureau of Special Licensing
150 North 18
th
Avenue, Suite 410
Phoenix, Arizona 85007
Legal First Name Legal Middle Name Legal Last Name
Previous AZ License #, (if
applicable)
Pursuant to Arizona Revised Statutes (A.R.S.) Title 36, Chapter 17 and Arizona Administrative Code (A.A.C.) Title 9,
Chapter 16, all requirements listed below must be submitted before a license can be issued by the Department.
Missing items or blank fields on the application will result in a request for the missing information and delay processing
of the application.
APPLICATION CHECKLIST
ADHS
Review
Application with all fields complete
A completed and signed Statement of Citizenship or Alien Status form (see attached form)
Photocopy of citizenship or authorized presence document (see attached list)
A transcript or equivalent documentation issued to the applicant from an accredited college or university
after the applicant’s completion of a master’s degree consistent with the standards of this state’s
universities, as required in A.R.S § 36-1940.01(A)(2)(a)
Documentation of the applicant’s completion of the ETSNESLP as required in ARS § 36-1940.01(A)(3)
Documentation of completing of a clinical practicum, as required in A.R.S § 36-1940.01(A)(2)(b)
Documentation of the applicant’s clinical fellowship agreement that includes:
• The applicant’s name, home address, and telephone address
• The clinical fellowship supervisor’s name, business address, telephone number, and speech-
language pathology license number
• The name and address where the clinical fellowship will take place,
• A statement by the clinical fellowship supervisor agreeing to comply with R9-16-209; and
• The signatures of the applicant and the clinical fellowship supervisor
If current legal name is different than the name on any of the documents submitted, provide a photocopy of
a name linkage document (marriage certificate, divorce decree, court order, etc.)
If convicted of a misdemeanor or felony (including DUI), photocopy of court records documenting
disposition and verification of completion of disposition must be submitted with application.
If the applicant has had a speech-language pathology license suspended, revoked, or had disciplinary
action taken against the professional license or certification, documentation that includes:
•
The date of the disciplinary action, revocation, or suspension;
•
The state, territory, or district of the U.S. that issued the disciplinary action, revocation, or
suspension; and
•
An explanation of the disciplinary action, revocation, or suspension
•
Any other applicable documents, including a legal order or settlement agreement
Revised 05.26.2020 2
If currently ineligible for licensing or certification in any state because of a license revocation or suspension,
provide a photocopy of documentation that includes:
•
The date of the ineligibility;
•
The state or jurisdiction of the ineligibility; and
•
An explanation of the ineligibility for licensing or certification.
An initial application fee of $100 plus an initial license fee of $100 via cashier’s check or money order made
payable to the Arizona Department of Health Services,
OR you may complete the attestation below to request an initial application and license fee waiver, per
A.R.S. § 41-1080.01.
NOTE: Do not sign the waiver attestation if you do not qualify and are paying the application
and license fees.
I, , attest that
(Printed Name of Applicant)
I am applying for this specific license for the first time in Arizona AND
My family income does not exceed 200% of the federal poverty guidelines.
Applicant’s Signature Date
NOT
E:
• A temporary license issued is effective for 12 months from the date of issuance.
• A temporary license may be renewed only once.
• An applicant issued a temporary speech-language pathologist license shall:
o Practice under the supervision of a licensed speech-language pathologist, and
o Not practice under the supervision of an individual who has a temporary speech-language pathologist
license
Revised 05.26.2020 3
APPLICANT INFORMATION
The applicant agrees to allow the Department to submit supplemental requests for information under A.A.C. R9-16-214(C). Yes No
Legal First Name
Legal Middle Name
Social Security Number (XXX-XX-XXXX)
Phone Number (XXX) XXX-XXXX
Email Address
Residential Street Address
Apt, Unit, etc. #
City
State
Zip Code
Mailing Street Address, if different than residential address
Apt, Unit, etc. #
City
State
Zip Code
If applicable, please provide your business information below:
Business Address
Suite, Unit, etc. #
City
State
Zip Code
Business Telephone Number
LICENSE/CERTIFICATION HISTORY
Do you hold other licenses as a speech-language pathologist in this or any other state or country?
Yes No
If you answered ‘Yes’ to the previous question, list the professional license or certification and the state or country in which it was issued. If you have
more than one, please include additional copies of this page with your application.
Professional License or Certification
State Issued
License/Certificate Number
Date Issued
Have you ever had a professional license or certificate not related to speech language pathology suspended or revoked by any state?
Yes No
If you answered ‘Yes’ to the previous question, please list:
The type of action taken against the professional
license or certificate:
The date of the action:
The state or jurisdiction that issued the action:
An explanation of the revocation or suspension:
Are you currently ineligible for licensing or certification in any state because of a license revocation or suspension?
Yes No
If you answered ‘Yes’ to the previous question, please list:
Revised 05.26.2020 4
Has any disciplinary action ever been imposed by any state, territory, or district in this
country for an act related to the applicant’s practice of speech
language pathology consistent with A.R.S Title 36, Chapter 17?
Yes No
If you answered ‘Yes’ to the previous question, please list:
The type of action taken against the professional
license or certificate:
The date of the action:
The state or jurisdiction that issued the action:
An explanation of the disciplinary action:
The type of action taken against the professional
license or certificate:
The date of ineligibility:
The state or jurisdiction:
An explanation of the ineligibility for licensing or certification:
EDUCATIONAL INFORMATION
Name of Institution
Degree, Certification, etc.
Date of Graduation (MM/YYYY)
Address of Institution
City
State
Other Institution(s) Attended (if applicable)
Degree, Certification, etc.
Date of Graduation (MM/YYYY)
Address of Institution
City
State
EMPLOYMENT (Current Employment Information)
I am not currently employed
Name of Current Employer
Position
Dates of employment (MM/YYYY-MM/YYYY)
Address of Employer
City
State
Zip Code
I do not have a supervisor
Supervisor’s Name
Supervisor’s Email Address
Supervisor’s Telephone Number
Additional Employer, if applicable
Position
Dates of employment (MM/YYYY-MM/YYYY)
Address of Employer
City
State
Zip Code
Applicant Legal First Name Applicant Legal Middle Name Applicant Legal Last Name
Employer Phone Number (XXX) XXX-XXXX
Revised 05.26.2020 5
I do not have a supervisor
Supervisor’s Name
Supervisor’s Email Address Supervisor’s Telephone Number
CRIMINAL HISTORY
Have you ever been convicted of a felony or misdemeanor? If ‘Yes,’
complete all fields.
Yes No
Was it a felony or misdemeanor?
Felony Misdemeanor
Date of Conviction (MM/DD/YYYY)
Court Name
State or Jurisdiction
Charge(s) convicted of
Disposition (sentencing information)
Completed sentence and all terms?
Yes No
Explanation (remember to also attach court record documenting disposition and verification of completion of disposition)
Applicant Legal First Name Applicant Legal Middle Name Applicant Legal Last Name
Revised 05.26.2020 6
CLINICAL FELLOWSHIP AGREEMENT
Please complete this agreement for each differing clinical site address and supervisor. If you have more than one, please include additional copies of
this page with your application.
Legal First Name
Legal Middle Name
Residential Street Address
Apt, Unit, etc. #
Phone Number (XXX)XXX-XXXX
City
State
Zip Code
Clinical Fellowship Supervisor’s First Name
Supervisor’s Last Name
Business Address
Suite, Unit, etc. #
City
State
Zip Code
Business Telephone Number
The name of where the clinical fellowship will take place
Business Address
Suite, Unit, etc. #
City
State
Zip Code
CLINICAL FELLOWSHIP SUPERVISORS
Arizona Administrative Code R9-16-209
Clinical Fellowship Supervisors
In addition to complying with the requirements in A.R.S. § 36- 1905, a clinical fellowship supervisor shall:
Complete a minimum of 36 supervisory activities throughout an individual's clinical fellowship that include:
• A minimum of 18 on-site observations,
• No more than six on-site observations in a 24-hour period, and
• A minimum of 18 monitor activities
As th
e clinical fellowship supervisor of this applicant, I agree to comply with Arizona Administrative Code R9-
16-209.
_______________________________________ ______________________
Signature of Supervisor Date
______________________________________ ______________________
Signature of Applicant Date
Revised 05.26.2020 7
NOTICE
S
• Pursuant to A.R.S. § 41-1030(B)(D)(E)(F)
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.
• Pursuant to section 41-1093.01, Arizona Revised Statutes, an agency shall limit all occupational regulations to regulations that are demonstrated to
be necessary to specifically fulfill a public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised
Statutes, you have the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction
to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.
APPLICANT ATTESTATION
I, ________________________________________________________________________, attest
(Printed Applicant Name)
that all information submitted as part of this application is true and accurate.
Applicant’s Signature
Date
Revised 07.13.2018
ARIZONA STATEMENT OF CITIZENSHIP
OR ALIEN STATUS FOR STATE PUBLIC BENEFIT
Bureau of Special Licensing
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 (A.R.S.) § 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:
1. All applicants must complete Sections I, II, and IV. Applicants who are not U.S. citizens or nationals
must also complete Section III.
2. 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.
a. If the document you submit does not contain a photograph, you must also provide a
government issued document that contains your photograph.
b. 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
Legal First Name Legal Middle Name Legal Last Name
Type of Application:
Initial Application
Renewal Application
Type of License/Certification:
Medical Radiologic Technologist
Speech Language Pathology
Midwifery
Laser Technician
Audiology
Hearing Aid Dispensing
SECTION II — CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a citizen or national of the United States?
Yes No
If you answered ‘Yes’ to the previous question, indicate place of birth:
City: _______________ State (or equivalent): _______________ Country or Territory: _______________
If you answered ‘Yes,’
1. Attach a legible copy of a document from the attached list.
Name of Document: __________________________________________________________________
2. Skip Section III and go to Section IV.
If you answered ‘No,’ complete sections III and IV.
8
Revised 07.13.2018
SECTION III — ALIEN STATUS DECLARATION
To be completed by applicants who are not citizens or nationals of the United States.
1. Please indicate alien status by checking the appropriate box below.
2. Attach a legible copy of a document from the attached list.
Name of Document: __________________________________________________________________
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).
10. Alien Paroled into the United States For Less Than One Year (8 U.S.C. § 1621(a)(3))
11. 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))
12. A nonimmigrant whose visa for entry is related to employment in the United States, or
13. 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.];
14. A foreign national not physically present in the United States.
Otherwise Lawfully Present
15. 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.
Signature of Applicant Date
9
Applicant's Legal First Name
Applicant's Legal Middle Name
Applicant's Legal Last Name
Revised 07.13.2018
ACCEPTABLE EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS
Per A.R.S. § 41-1080, you must submit one of the documents in the list below to verify authorized presence in
the United States.
Please note:
1. If the name on the document submitted is NOT your current legal name, you MUST provide a
legal name linkage document (i.e. marriage certificate, court order, etc.)
2. If the document submitted does NOT contain your photograph, you MUST provide another
government issued document that contains a photograph.
Acceptable Documents:
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 (Illinois,
New Mexico, Utah, and Washington (except for ‘Enhanced’ credentials) do not verify lawful
presence in U.S.)
3. A birth certificate or delayed birth certificate issued in any state, territory or
possession of the United States.
4. A United States certificat
e of birth abroad.
5. A United States passport.
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 certificat
e of naturalization.
10. A United States certific
ate 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 i
ssued 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.
10
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TEMPORARY SPEECH-LANGUAGE PATHOLOGIST INITIAL APPLICATION Bureau of Special (Arizona Department of Health Services)

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Completed 8 February 2021

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