License: 08 Retired PTA Status

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ARIZONA STATE BOARD OF PHYSICAL THERAPY Application ~ Retired Status Physical Therapist Assistant 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 retired Certified physical Therapist Assistant in the state of Arizona. I hold retired certificate number _______________. Date of Birth: ________________________ SSN: ________________ _________ ________________ Current Mailing Address: _________________________________________________________________________ Number/Street/Apartment Number ____________________________________________________(_____)_____________________________ City State Zip Area Code Telephone number Email Address: ________________________________________________________________________________ I affirm that I retired from engaging in the work of a physical therapist assistant on _________________________ Date of Retirement Signature: ________________________________________ Date: __________________________ I affirm that I understand that I may not engage in the work of a physical therapist assistant. 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 for PTA Retired Status 5/18