DO NOT USE this form if you have ever been a licensed PT or certified PTA in Arizona.  Previous or current AZ licensed PTs and certified PTAs must log into eLicensing to submit a Service Request for a license verification to be sent to another licensing board. If you have trouble logging into eLicensing contact staff. 

USE THIS FORM ONLY if you are a 3rd Party entity requesting verification of an Arizona licensed PT or certified PTA. Complete this form and submit with payment to request an official verification of licensure to be sent to another licensing board or college/university.