License: 07 Inactive PTA Status

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ARIZONA STATE BOARD OF PHYSICAL THERAPY Application ~ Inactive Status Physical Therapist Assistant A.R.S. § 32-2031 (A): The board shall place a licensee or certificate holder on inactive status and waive the continuing competence requirements if a licensee or certificate holder presents a written affidavit to the board that the licensee or certificate holder is not currently engaged in the practice of physical therapy or working as a physical therapist assistant in this state, is in good standing with the board and has paid all fees required by this chapter. I, __________________________________________________________________________, am an inactive Certified Physical Therapist Assistant in the state of Arizona. I hold inactive certificate number _______________. Date of Birth: ________________________ SSN: ________________ _________ ________________ Current Mailing Address: _________________________________________________________________________ Number/Street/Apartment Number ____________________________________________________(_____)_____________________________ City State Zip Area Code Telephone number Email Address: ________________________________________________________________________________ Signature: _________________________________________ Date: _____________________________ I affirm that my Arizona PTA certificate is in good standing with the Board. Signature: ________________________________________ Date: __________________________ I affirm that I understand that I may not engage in work as a PTA in the state of Arizona. Signature: ________________________________________ Date: __________________________ Submit via eLIcensing Portal Only (https://elicense.az.gov/) Application PTA Inactive Status 12/17