Ariz. Admin. Code § 4-21-201

Current through Register Vol. 30, No. 44, November 1, 2024

Section R4-21-201 - Licensure by Examination

A. An individual is eligible to apply for licensure by examination if the individual graduated from an accredited optometry program but is not eligible for licensure by endorsement under R4-21-202(A).

B. To apply for licensure by examination, an individual who is eligible under subsection (A) shall submit an application form, which is available from the Board, and provide the following information about the applicant:

1. Full legal name;

2. Other names ever used, if any, and if applicable, a copy of the court document or marriage license resulting in a name change;

3. Social Security number;

4. Mailing address;

5. E-mail address, if any;

6. Residential, business, and mobile telephone numbers, if applicable;

7. Date and place of birth;

8. Residential addresses for the past five years;

9. Educational background including the name and address of, dates of attendance at, and date of graduation from:

a. An accredited optometry program,

b. A pre-optometric school or undergraduate educational institution, and

c. Other post-secondary schools attended, if any;

10. Experience in the practice of the profession of optometry including the business form and location of the practice;

11. Work experience or occupation, other than the practice of the profession of optometry, for the past five years;

12. List of the states in which the applicant is professionally licensed including the name of the state, type of professional license, date issued, and expiration date;

13. List of the states in which the applicant was but no longer is professionally licensed including the name of the state, type of professional license, date issued, and reason the license is no longer valid;

14. Statement of whether the applicant:

a. Has ever been denied the right to take an examination for optometric licensure by any state or jurisdiction and if so, the name of the state or jurisdiction, date, and reason for the denial;

b. Has ever been denied an optometric license or renewal in any state or jurisdiction and if so, the name of the state or jurisdiction, date, and reason for the denial;

c. Has ever had a license or certificate of registration to practice the profession of optometry suspended or revoked by any optometric licensing agency and if so, the name of the optometric licensing agency, date, reason for the suspension or revocation, and current status;

d. Has ever had an investigation conducted or has an investigation pending by an optometric regulatory agency of any state or jurisdiction and if so, name of the optometric regulatory agency and state or jurisdiction, date, reason for the investigation, and current status;

e. Has ever had a disciplinary action instituted against the applicant by any optometric licensing agency and if so, the name of the optometric licensing agency, date, nature of the disciplinary action, reason for the disciplinary action, and current status;

f. Has ever been convicted of, pled guilty or no contest to, or entered into diversion in lieu of prosecution for any criminal offense in any jurisdiction of the United States or foreign country and if so, name of the jurisdiction, date, offense charged, offense for which convicted, pled guilty, or no contest, and current status;

g. Is currently, or has ever been addicted to narcotic substances or habitually abused alcohol within the last 10 years. If so, dates during which the addiction or abuse occurred, steps taken to address the addiction or abuse, current status, and a statement as to why the addiction or abuse does not amount to unprofessional conduct.

15. Dated and sworn signature of the applicant verifying that the information provided is true to the best of the applicant's knowledge, information, and belief.

C. In addition to submitting the application form required under subsection (B), an applicant shall submit or have submitted on the applicant's behalf:

1. A passport-quality photograph of the applicant's head and shoulders that is taken within six months of the date of application and signed by the applicant in ink across the lower portion of the front side;

2. A full set of readable fingerprints taken by a criminal justice agency for the purpose of obtaining a state and federal criminal records check;

3. To process the fingerprints; a cashier's check or money order payable to the Arizona Department of Public Safety in the amount listed on the application for licensure;

4. The application fee required under A.R.S. § 32-1727;

5. A copy of the scores obtained by the applicant on Parts I, II, and III of the National Board of Examiners in Optometry examination less than ten years before the date of the application;

6. A passing score obtained by the applicant on the jurisprudence examination described at R4-21-203;

7. An official transcript submitted directly to the Board by the educational institution with an accredited optometry program from which the applicant graduated with a degree in optometry;

8. An official transcript submitted directly to the Board by the educational institution at which the applicant took pre-optometry or undergraduate courses;

9. A self-query from the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank made within three months before the date of application; and

10. A copy of the front and back of a current CPR card issued to the applicant.

Ariz. Admin. Code § R4-21-201

Adopted effective February 7, 1986 (Supp. 86-1). Amended effective April 1, 1991 (Supp. 91-2). Amended effective November 5, 1998 (Supp. 98-4). Amended by final rulemaking at 6 A.A.R. 3812, effective September 13, 2000 (Supp. 00-3). Amended by final rulemaking at 11 A.A.R. 1864, effective May 3, 2005 (Supp. 05-2). Amended by final rulemaking at 14 A.A.R. 12, effective February 2, 2008 (Supp. 07-4). Amended by final rulemaking at 16 A.A.R. 2383, effective November 16, 2010 (Supp. 10-4). Amended by final rulemaking at 22 A.A.R. 328, effective 3/28/2016.