License: 08 Retired PT Status

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ARIZONA STATE BOARD OF PHYSICAL THERAPY Application for Physical Therapist *Retired* Status A.R.S. § 32-2031 (A): The Board shall place a licensee or certificate holder on retired status and waive the renewal fee and continuing competence requirements if a licensee or certificate holder presents a written affidavit to the board that the licensee or certificate holder has retired from the practice of physical therapy or from work as a physical therapist assistant, is in good standing with the board and has plaid all fees required by this chapter before the waiver. I, __________________________________________________________________________, am a Licensed Physical Therapist in the state of Arizona. I hold active license number ___________________________. Date of Birth: ________________________ SSN: ________________ _________ ________________ Current Mailing Address: _________________________________________________________________________ Number/Street/Apartment Number ____________________________________________________(_____)_____________________________ City State Zip Area Code Telephone number I affirm that I retired from the practice of physical therapy on ________________________________ Date of Retirement Signature: ________________________________________ Date: __________________________ I affirm that my Arizona PT license is in good standing with the Board. Signature: ________________________________________ Date: __________________________ I affirm that I understand that I may not engage in the practice of physical therapy. Signature: ________________________________________ Date: __________________________ Under penalty of perjury, I declare and affirm that the statements made in this Application for Inactive Status are complete and correct and that any false or misleading information may be cause for denial or disciplinary action. To the best of my knowledge and belief I am not in violation of the provisions of the Arizona Physical Therapy Law. ___________________________________________ Signature of Applicant Submit via eLIcensing Portal Only (https://elicense.az.gov/) Application PT Retired Status 05/18