Public Information And Records Request Home Public Information And Records Request What type of request are you submitting? Licensee List Public Records Customer Information First name Last Name Email Email Confirm email Phone Address City State Zip Public Record Public Record Request Options Complaint File Only Licensing File Only Entire Public File Board Meeting(s) - Minutes Board Meeting(s) - Audiotapes/Compact Discs Psychologist or Behavior Analyst Name License Number Minutes date(s) and/or description If you wish to purchase an audiotape or compact disc of a public session of a Board meeting, the cost is $10.00 per audiotape or compact disc. Please write out the dates and description of what is requested. Public Record or License/Certificate Verification Option Psychologist/Behavior Analyst Name Psychologist/Behavioral Analyst License Number Would like this verification to be sent via email or regular mail? Email Regular Mail Verify Email Shipping Address City State Zip Licensee List All Licensees Ever Licensed All Licensees Ever Licensed $0.05/name Licensee List Options All Active Licenses $0.25/name All Active and Inactive Licenses $0.25/name All Active Licenses(residing in Arizona only) $0.25/name All Active and Inactive Licenses(residing in Arizona only) $0.25/name Custom List(By choosing any of these options, the price will automatically increase to $0.35/name) Public Phone Number Licensed Date License Number License Expiration Date Additional Notes Commercial Use Is this request going to be used for commercial use? Yes No REQUESTING PARTY: PLEASE READ AND NOTE THE FOLLOWING INFORMATION AND INSTRUCTIONS photographs of public records for commercial purposes must provide a STATEMENT setting forth the commercial purpose for which they will be used. A person providing a verified statement setting forth the commercial purpose for which the reproduction will be used may be furnished such reproductions at the discretion of the custodian of the records for a charge reflecting the following: A portion of the cost to the State for obtaining the documents or records to be reproduced. A reasonable fee covering the cost of time, equipment and personnel in making the reproduction, and The value of reproduction on the commercial market. If the custodian of a public record believes that the commercial purpose of a reproduction is a misuse of public records or an abuse of the right to receive them, he or she may refuse a request for reproduction of such record for said commercial purpose and may request the Governor to prohibit the furnishing of reproductions for such commercial purposes by Executive Order. If an Executive Order is not issued within thirty (30) days of the custodian’s application, the requesting party will be furnished such reproductions for the commercial purpose set forth in his other verified statement. “Commercial Purpose” is broadly defined by the Act as “any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of such public record.” A.R.S. §39-121.03E. “Commercial Purpose” includes copies of records for sale or resale and copies of printouts of names and addresses for purposes of solicitation of business. IMPORTANT: SUBSECTION D OF A.R.S. §39-121.03 PROVIDESTHAT: A person who obtains public records for a commercial purpose without indicating the commercial purpose or who obtains a public record for a non-commercial purpose and uses or knowingly allows the use of such public record for a commercial purpose or obtains a public record for a commercial purpose and uses or knowingly allows the use of such public record for a different commercial purpose or obtains a public record from any one other than the custodian of such records and uses them for a commercial purpose shall in addition to other penalties* be liable to the state or the political subdivision from whom the public record was obtained for damages in the amount of three times the actual damages if it can be shown that the public record would not have been provided had the commercial purpose of actual use been stated at the time of obtaining the records. *The penalty for perjury is a fine of not less than $500 nor more than $5,000, or imprisonment in the State Prison for not less than one nor more than fourteen years, or both. S W O R N S T A T E M E N T I declare that I have read the information and instruction sheet accompanying this form and understand the contents therein. I further declare that the copies or other reproductions of the public records described above and which I have requested are to be used solely for commercial purposes. If the records are to be used for commercial purposes, specifically state those purposes: I further declare that such copies or reproductions will not be used directly or indirectly for a different purpose other than described above. I further declare under penalty of perjury that the foregoing is correct and true. Enter your full name to confirm CAPTCHA What code is in the image? Enter the characters shown in the image. Submit Leave this field blank
