Annual Naturopathic Physicians Medical License Renewal Application (Page 2 of 2) in pdf

ANSWER ALL OF THE FOLLOWING QUESTIONS

Since your last renewal

1. Were you arrested, charged with, convicted of, or enter into a plea of no contest to any criminal act?

yes

2. Did any licensing agency or board [other than this board] initiate or take any action against any

license or certificate that is or was held by you?

yes

3. In lieu of disciplinary action, did you enter into a consent agreement of stipulation with any agency?

yes

4. Were you named in any malpractice suit?

yes

5. Do you have a complaint pending before any agency?

yes

In the event that the response to any of the questions above is “yes”, you must file with the renewal a detailed report concerning the matter.

NOTE:

1. CITIZEN STATUS DECLARATION: Are you a United States Citizen? _____Yes ______No If yes, skip question 2.

2. Are you a legal resident authorized to work in the United States _____Yes ______No If yes to 2. Provide the Board with proof of

current legal resident status.

I ATTEST THAT ALL INFORMATION SUBMITTED ON AND WITH THIS RENEWAL APLICATION IS TRUE.

___________________________

__________________________________________________________________

Date (Required)

Signature (Required)

LICENSURE RENEWAL CHECK LIST

PLEASE BE AWARE: you must allow at least 30 days for processing of your renewal. If you wait until the end of December to renew your

license, it will not be processed until 2015. Licensure renewals are processed in the order they are received. Incomplete or non-legible forms will NOT

BE PROCESSED. Renewal forms and payment must be received together. THE BOARD NO LONGER SENDS HARD COPIES VIA MAIL. YOU

WILL RECEIVE THE LICENSE VIA EMAIL.

DID YOU:

Complete the renewal form, making sure all required information is provided. Incomplete forms will not be processed.

2016 License Renewal Fee $165.00, If postmarked after January 1, 2016, you must include a LATE FEE OF $83.00. (This fee cannot be waived,

there are no exceptions.)

Include all applicable fees.

Please Be Aware: IF THE LICENSE IS NOT RENEWED WITHIN 60 DAYS OF THE EXPIRATION DATE, YOUR LICESNE WILL

AUTOMATICALLY EXPIRE. IF YOU ARE BEING AUDITED FOR CME you would have/ or will be notified by the Board, and will need to

provide proof of CME for the LAST THREE YEARS, along with this renewal form.

ACCEPTABLE FORM OF PAYMENT: Personal check or money orders are the only forms of payment accepted with this form.

DO NOT SEND CASH OR PROVIDE A CREDIT CARD NUMBER. Make payment directly to: The AZ. Naturopathic Medical Board

THERE WILL BE A $25.00 FEE FOR RETURNED CHECKS

Mailing Address: 1400 W. Washington, Ste. 230

ONLINE RENEWAL IS ALSO AN OPTION

Phoenix, AZ 85007

Pursuant to A.R.S. § 41-1030 (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 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.

Pursuant to A.R.S. §41-1030 (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 violation of

this section. Pursuant to A.R.S. §41-1030 (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. Pursuant to A.R.S. §41-1030 (F) This section does not

abrogate the immunity provided by Section 12-820.01 OR 12-820.02.

Revised 7/2015

For Board Use

Emailed

Agenda

Receipted