Arizona Administrative Code
Title 4 - PROFESSIONS AND OCCUPATIONS
Chapter 6 - Board Of Behavioral Health Examiners
Article 3 - LICENSURE
Section R4-6-301 - Application for a License by Examination

1. A statement by the applicant certifying that all information submitted in support of the application is true and correct;

2. Identification of the license for which application is made;

3. The license application fee required under R4-6-215;

4. The applicant's name, date of birth, social security number, and contact information;

5. Each name or alias previously or currently used by the applicant;

6. The name of each college or university the applicant attended and an official transcript for all education used to meet requirements;

7. Verification of current or previous licensure or certification from the licensing or certifying entity as follows:

8. Background information to enable the Board to determine whether, as required under A.R.S. § 32-3275(A)(3), the applicant is of good moral character;

9. A list of every entity for which the applicant has worked during the last 7 years;

10. If the relevant licensing examination was previously taken, an official copy of the score the applicant obtained on the examination;

11. A report of the results of a self-query of the National Practitioner Data Bank;

12. Documentation required under A.R.S. § 41-1080(A) showing that the applicant's presence in the U.S. is authorized under federal law;

13. A completed and legible fingerprint card for a state and federal criminal history background check and payment as prescribed under R4-6-215 if the applicant has not previously submitted a full set of fingerprints to the Board, or verification that the applicant holds a current fingerprint card issued by the Arizona Department of Public Safety; and

14. Other documents or information requested by the Board to determine the applicant's eligibility.