R9-16-303. Application

A. An applicant for licensure shall submit to the Department: 1. An application in a Department-provided format that contains: a. The applicant’s name, home address, telephone number, and email address; b. The applicant’s Social Security number, as required under A.R.S. §§ 25-320 and 25-502; c. The applicant’s current employment, if applicable, including: i. The employer’s name, ii. The applicant’s position, iii. Dates of employment, iv. The address of the employer, v. The supervisor’s name, vi. The supervisor’s email address, and vii. The supervisor’s telephone number; d. Whether the applicant has ever been convicted of a felony or a misdemeanor in this or another state or jurisdiction; e. If the applicant was convicted of a felony or misdemeanor: i. The date of the conviction, ii. The state or jurisdiction of the conviction, iii. An explanation of the crime of which the applicant was convicted, and iv. The disposition of the case; f. Whether a hearing aid dispenser license issued to the applicant has been suspended or revoked; g. Whether the applicant is currently ineligible to apply for a hearing aid dispenser license due to a prior revocation or suspension of the applicant’s hearing aid dispenser license; h. Whether the applicant has been disciplined by any state, territory or district in this country for an act upon the applicant’s hearing aid dispenser license; i. Whether the applicant agrees to allow the Department to submit supplemental requests for information under R9-16-314; j. An attestation that the information submitted as part of the application is true and accurate; and k. The applicant’s signature and date of signature; 2. Documentation of the applicant’s citizenship or alien status that complies with A.R.S. § 41-1080; 3. Documentation that the applicant received a high school diploma, a high school equivalency diploma, an associate degree, or a higher degree; 4. Whether a professional license or certificate has been revoked or suspended by another state or jurisdiction; 5. If a license for an applicant has been revoked or suspended by any state, documentation that includes: a. The date of the revocation or suspension, b. The state or jurisdiction of the revocation or suspension, and c. An explanation of the revocation or suspension; 6. If an applicant is currently ineligible for licensing in any state because of a license revocation or suspension, documentation that includes: a. The date of the ineligibility for licensing, b. The state or jurisdiction of the ineligibility for licensing, and c. An explanation of the ineligibility for licensing; 7. If an applicant has been disciplined by any state, territory or district, in this country for an act upon the applicant’s hearing aid dispenser license, documentation that includes; a. The date of the disciplinary action, b. The state or jurisdiction of the disciplinary action, c. An explanation of the disciplinary action, and d. Any other applicable documents, including a legal order or settlement agreement; and 8. A nonrefundable application fee specified in R9-16-316. B. The Department shall review an application and documentation according to R9-16-314 and Table 3.1.