Annual Naturopathic Physicians Medical License Renewal Application
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2ANNUAL NATUROPATHIC PHYSICIANS MEDICAL LICENSE RENEWAL APPLICATION
The renewal form and payment must be received together. Incomplete or non-legible forms will not be processed. FEES are non-refundable.
2016 LICENSE RENEWAL FEE: $165.00 A license must be renewed on or before
YOU MAY RENEW ONLINE AT
January 1, 2016 LATE FEE $83.00 (REQUIRED IF APPLICATION IS POST MARKED AFTER January 1, 2015) The late fee cannot
be waived
PHYSICIAN
NAME:____________________________________________________________________________________________________
First
Middle
Last
LICENSE NO:_________ -___________ DATE OF INITIAL ISSUANCE ______/_______/________
ADDRESS: Every physician must have an address available to the public. If only one address is provided, even if it is your home address, it will be available to the public.
Primary Office Address: This is the office/principle place of business. Secondary Location Address: Any other location in which you conduct business/maintain a
continued activity. Home Address: You are required to provide a home address and phone number. They will not be released to the public unless you fail to provide an
office address. Mailing Address: Please provide a mailing address, this will be the location the renewed license(s) will be mailed. Email Address: This address is optional
and will not be provided to the public, however in an effort to keep Board costs at a minimum and licensing fees from increasing, the Board will be emailing appropriate
Board correspondence to our licensees.
EMAIL ADDRESS:______________________________________________________________________________________________________
PRIMARY OFFICE ADDRESS: PRACTICE NAME:__________________________________________________________________________
OFFICE ADDRESS:______________________________________________________________________________________________________
Ste. No.
City
State
Zip
OFFICE PHONE:_____________________________FAX:__________________________
SECONDARY OFFICE LOCATION(S): PRACTICE NAME:_____________________________________________________________________
OFFICE ADDRESS:________________________________________________________________________________________________________
Ste. No.
City
State
Zip
OFFICE PHONE:____________________________FAX:___________________________
If you have additional locations, use a separate piece of paper to list all information required.
HOME ADDRESS: ________________________________________________________________________________________________________
City
State
Zip
CELL PHONE:______________________________
Primary Office Address
Home Address
Other - (provide Board with complete address)
MAILING ADDRESS:
Check One
(Other )______________________________________________________________________________________________________________
FAILURE TO COMPLETE THE REQUIRED CME MAY BE CONSIDERED UNPROFESSIONAL CONDUCT.
I understand the above statement
Check Box to Confirm
ANSWER THE ONE QUESTION THAT BEST APPLIES TO YOUR RENEWAL.
In accordance with A.A.C. R4-18-205 I have completed a minimum of 30 hours of CME during 2015, 10 hours of the 30 CME hours
have been in pharmacology and at least 8 hours have been from an approved naturopathic organization.
I graduated and my initial license was issued by the Board in 2015. I am not required to comply with the CME requirements until
2016. (This only applies to students who have recently graduate. Doctors who are newly licensed by endorsement from another state
must comply with the CME requirements.)
I am requesting retirement of my medical license in the State of Arizona to practice naturopathic medicine. I am not required to
submit CME for renewal.
***Do not submit proof of CME unless you received notice you are subject to a CME audit.
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