Get Yellow Fever Vaccine Center Application - Arizona Department Of ... - Azdhs

Filling out the Yellow Fever Vaccine Center Application is an essential step for those looking to become certified vaccination centers in Arizona. This guide provides clear and concise instructions to assist users in completing the application form with ease.

Follow the steps to accurately complete your application online.

1. Press the ‘Get Form’ button to access the application and open it in the designated editing interface.
2. Enter the applicant's first and last name, along with their professional title in the respective fields.
3. Provide the name of the clinic or pharmacy, followed by the complete address which includes the street, city, state, and zip code.
4. Fill in the phone number and fax number in the provided fields to ensure proper communication.
5. Specify the contact person for the application by providing their first name, last name, and title.
6. Add the contact person's email address to facilitate further correspondence.
7. If you are a physician applicant, input your Arizona medical license number and its expiration date. If you represent a pharmacy, enter the Arizona pharmacy license number.
8. Include information for any additional pharmacy locations by attaching an additional sheet with required details.
9. For nurse practitioner applicants, enter the Arizona nursing license number and its expiration date.
10. Sign and date the application to certify the information provided is accurate and complete.
11. Check the box confirming that all healthcare providers and staff have completed the CDC Yellow Fever online training program.
12. Finally, submit the completed form along with any necessary documentation to the Arizona Department of Health Services at the specified address.

Complete your Yellow Fever Vaccine Center Application online today!