Before the
expiration date of a speech-language pathologist assistant license, a licensee
shall submit to the Department:
1. An
application in a Department-provided format for renewal of a speech-language
pathologist assistant license that contains:
a. The licensee's name, home address,
telephone number, and e-mail address;
b. The licensee's current employment, if
applicable, including:
i. The employer's
name,
ii. The licensee's
position,
iii. Dates of
employment,
iv. The address of the
employer,
v. The supervisor's
name,
vi. The supervisor's e-mail
address, and
vii. The supervisor's
telephone number;
c. If
applicable, the name of the licensee's supervising speech-language
pathologist;
d. The licensee's
license number and date of expiration;
e. Since the previous license application,
whether the licensee has been convicted of a felony or a misdemeanor involving
moral turpitude in this or another state;
f. If the licensee has been convicted of a
felony or a misdemeanor:
i. The date of the
conviction,
ii. The state or
jurisdiction of the conviction,
iii. An explanation of the crime of which the
licensee was convicted, and
iv. The
disposition of the case;
g. Whether the licensee has had a license
revoked or suspended by any state within the previous two years;
h. Whether the licensee is currently
ineligible for licensure in any state because of a prior license revocation or
suspension;
g.
i. Whether the licensee agrees to allow the Department
to submit supplemental requests for information under
R9-16-506 ;
j. An attestation that the licensee has
completed continuing education required under A.R.S.
36-1904 and this Article and
documentation of completion is available upon request;
h.
k. An
attestation that the information required as part of the renewal application is
true and accurate; and
i.
l. The licensee's
signature and date of signature;
2. If a license for a licensee has been
revoked or suspended by any state within the previous that two years,
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;
3. If the
licensee is currently ineligible for licensure in any state because of a prior
license revocation or suspension, documentation that includes:
a. The date of the ineligibility for
licensure,
b. The state or
jurisdiction of the ineligibility for licensure, and
c. An explanation of the ineligibility for
licensure;
2. In a Department-provided
format, documentation of continuing education as required in R9-16-504 and
completed within 24 months before the expiration date on the license,
including:
a.
The name of the individual or organization providing
the course;
b.
The date and location where the course was
provided;
c.
The title of each course attended;
d.
A description of each course's
content;
e.
The name of the instructor;
f.
The instructor's education, training, and experience
background, if applicable; and
g.
The number of continuing education hours earned for
each course; and
