B. To apply for renewal
of a license, a licensee shall:
1. Complete a
license renewal application form and provide the following information:
a. Applicant's full name;
b. Applicant's Arizona license
number;
c. Applicant's mailing,
permanent, and e-mail addresses and telephone number;
d. Applicant's highest educational
degree;
e. Applicant's employment
status;
f. Applicant's principal
field of employment;
g. Current
employer's name and address;
h.
Current supervisor's name and telephone number;
i. Applicant's physical description,
including height, weight, and eye and hair color;
j. A statement whether, since the time of
last application, the applicant:
i. Has been
arrested for, has pled guilty or no contest to, or has been convicted of a
felony, misdemeanor, or undesignated offense, and if the answer is yes, a
complete explanation, including place, date, charge, and a copy of any
pertinent documentation such as a court order or plea agreement;
ii. Has been arrested for a traffic violation
that resulted in a fine greater than $150, and if the answer is yes, a complete
explanation, including date, offense, and a copy of any pertinent documentation
such as a court order;
iii. Has
been named in a civil or malpractice lawsuit relating to the applicant's
employment as a respiratory care practitioner, and if the answer is yes, a
complete explanation;
iv. Has been
or is subject to any disciplinary action, consent order, or settlement
regarding the applicant's license in any jurisdiction, and if the answer is
yes, a complete explanation;
v. Has
abused illegal substances, prescription drugs, or alcohol or been enrolled or
committed to a substance-abuse or alcohol-treatment program, and if the answer
is yes, a complete explanation, including date, place, and copy of any
documentation of program completion; and
vi. Has been disciplined, suspended, or
terminated from employment as a respiratory care practitioner, and if the
answer is yes, a complete explanation;
k. A statement of whether the applicant is in
compliance with all federal and state law regarding storage, transfer, and
access to medical records;
l.
Evidence of the applicant's U.S. citizenship, alien status, legal residency, or
lawful presence in the U.S.; and
m.
The applicant's certification that the information provided is true and
complete;
2. Pay the
renewal fee prescribed in
R4-45-102(A)(4);
and
3. Complete the required
continuing education units.
