1. 1. The following information in a Department-provided format:

   1. a. The applicant’s name;
   2. b. The applicant’s residential address and, if different, mailing address;
   3. c. The applicant’s telephone number;
   4. d. The applicant’s email address;
   5. e. The applicant’s Social Security number, as required under A.R.S. §§ 25-320 and 25-502;
   6. f. The applicant’s date of birth;

   7. g. The applicant’s current employment in the radiation technology field, if applicable, including:

      1. i. The employer’s name,
      2. ii. The applicant’s position,
      3. iii. Dates of employment,
      4. iv. The address of the employer,
      5. v. The supervisor’s name,
      6. vi. The supervisor’s email address, and
      7. vii. The supervisor’s telephone number;
   8. h. The applicant’s educational history related to radiation technology, including:

   9. i. The name and address of each educational institution,

      1. ii. The degree or certification received, and
      2. iii. The applicant’s date of graduation;
      3. i. The type of certificate being applied for;
   10. j. Whether the applicant has ever been convicted of a felony or a misdemeanor in this or another state;

   11. k. If the applicant has been convicted of a felony or a misdemeanor:

       1. i. The date of the conviction,
       2. ii. The state or jurisdiction of the conviction,
       3. iii. An explanation of the crime of which the applicant was convicted, and
       4. iv. The disposition of the case;

   12. l. Whether the applicant holds other professional licenses or certifications and, if so:

       1. i. The professional license or certification, and
       2. ii. The state in which the professional license or certification was issued;
   13. m. Whether the applicant has had a professional license or certificate suspended, revoked, or had disciplinary action taken against the professional license or certificate;
   14. n. Whether the applicant agrees to allow the Department to submit supplemental requests for information under R9-16-621;
   15. o. An attestation that the information submitted as part of an application is true and accurate; and
   16. p. The applicant’s signature and date of signing;

2. 2. If the applicant has had a professional license or certificate suspended, revoked, or had disciplinary action taken against the professional license or certificate within the previous five years, documentation that includes:

   1. a. The date of the disciplinary action, revocation, or suspension;
   2. b. The state or nationally accredited certifying body that issued the disciplinary action, revocation, or suspension; and
   3. c. An explanation of the disciplinary action, revocation, or suspension;

3. 3. If the applicant is currently ineligible for licensing or certification in any state because of a license revocation or suspension, documentation that includes:

   1. a. The date of the ineligibility for licensing or certification,
   2. b. The state or jurisdiction of the ineligibility for licensing or certification, and
   3. c. An explanation of the ineligibility for licensing or certification; and
4. 4. Documentation for the applicant that complies with A.R.S. § 41-1080.

An applicant for certification shall submit to the Department:

Historical Note

New Section made by final expedited rulemaking at 25 A.A.R. 2409, effective August 27, 2019 (Supp. 19-3). Amended by final expedited rulemaking at 31 A.A.R. 672 (February 28, 2025), with an immediate effective date of February 4, 2025 (Supp. 25-1).