:: AZBOP Online Applications ::

Application for Medical Gas or DME Supplier Permit

Instructions

Physical Location ResidentNon-Resident

Secondary Type Gas Supplier/DMEGas SupplierDurable Medical Equipment

Applicable Statutes and Rules

Please familiarize yourself with the statutes and rules listed below.

Statutes

A.R.S. § 32-1927.02, 1929, 1930, 1931, 1933, 1939

Rules

A.A.C R4-23-601, 602

A.A.C R4-23-692 (CMG Distributor),R4-23-693 (CMG/DME Supplier)

Click here to review the statutes and rules

I have read and understand the statutes and rules.

Business Information

Business Name

FEIN

Physical Street Address

Physical Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Physical Zip Code

Physical City

Physical State

Physical County

Phone

Ext

Fax

Email [email protected]

Check if mailing address is the same as above.

Street Address

Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code

City

State

County

Ownership Information

Name of owner(s)

Phone

Ext

Fax

Is this entity a corporation or partnership with officers or partners? If yes, provide the name, title and address of each officer or partner. You may enter this information here or attach a list later in the application process.

YesNo

Is this application being submitted because of a change in ownership?

YesNo

If yes, indicate the former owner's name, AZ permit number, and permit name.

Other Business Information

Indicate the date your business opened or will open

Has this entity ever operated under any other trade or business names? If yes, indicate the trade or business names used.

YesNo

Has this entity ever operated a similar business in any other state or jurisdiction? If yes, provide the name and location of each similar business. You may enter this information here or attach a list later in the application process.

YesNo

Regulatory Questions

Has the owner, any officer or active partner, ever been convicted of an offense involving moral turpitude, a felony offense, or any drug-related offense or have any currently pending felony or drug-related charges? If yes, provide full details, which must include the charge, conviction date, jurisdiction and location. YesNo Date Name of Owner/Officer Charges State or Jurisdiction Location Upload
Has any formal disciplinary action ever been taken against any of the permits held by this business at either a state or federal level? If yes, provide full details, which must include the nature and date of each action and the state or jurisdiction involved. You must also provide copies of the orders relating to each disciplinary action. YesNo Date Nature of Action State or Jurisdiction Upload
Are there any disciplinary actions or sanctions pending against any of the permits held by this business at either a state or federal level? If yes, provide full details. YesNo
Has the owner, any officer or active partner ever been denied a permit in this state or any other jurisdiction? If yes, provide full details, which must include the state or jurisdiction and the date of the denial. You must also provide a copy of the Order or letter of denial. YesNo Date State or Jurisdiction Upload

Has the owner, any officer or active partner, ever been convicted of an offense involving moral turpitude, a felony offense, or any drug-related offense or have any currently pending felony or drug-related charges? If yes, provide full details, which must include the charge, conviction date, jurisdiction and location.

YesNo

Has any formal disciplinary action ever been taken against any of the permits held by this business at either a state or federal level? If yes, provide full details, which must include the nature and date of each action and the state or jurisdiction involved. You must also provide copies of the orders relating to each disciplinary action.

YesNo

Are there any disciplinary actions or sanctions pending against any of the permits held by this business at either a state or federal level? If yes, provide full details.

YesNo

Has the owner, any officer or active partner ever been denied a permit in this state or any other jurisdiction? If yes, provide full details, which must include the state or jurisdiction and the date of the denial. You must also provide a copy of the Order or letter of denial.

YesNo

Designated Representative Information

Name of Manager Or Responsible Person

Email Address

Emergency Phone Number

Ext

Address

Zip Code

City

State

County

Attachments

Review Your Information

Affirm And Submit

I declare under penalty of perjury under the laws of the state of Arizona that the information I have provided in this application is true and correct to the best of my knowledge.

E-Signature :

Date :

Please be advised of the following pursuant to Arizona Revised Statutes (A.R.S.) § 41-1030:

A.R.S. § 41-1030 (B)

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

A.R.S. § 41-1030 (D)

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A.R.S. § 41-1030 (E)

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.

A.R.S. § 41-1030 (F)

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.