Current through Register 1518, March 29, 2024
(1)
Contents of the Application Form for a Full License.
The Committee's application form for a full license will request the following
information:
(a) the applicant's name; date
and place of birth; and home address, mailing address and principal business
address;
(b) the applicant's social
security number;
(c) a photograph
of the applicant adequate for positive identification;
(d) a written statement asserting that the
applicant is of good moral character. This statement must be executed by
someone who is unrelated to the applicant and who has known the applicant well
and for a minimum of three years, preferably an acupuncturist licensed to
practice in Massachusetts;
(e) a
statement of the applicant's involvement in civil litigation related to the
practice of acupuncture, and any criminal litigation;
(f) a statement of any disciplinary action
taken against the applicant;
(g) a
statement of the other jurisdictions in which the applicant is or has been
licensed to practice acupuncture, including license numbers and issue
dates;
(h) a statement of the
results of any acupuncture licensure examination the applicant has
taken;
(i) a statement of the
applicant's physical and mental health, including an explanation of any
dysfunction impairing him as a student or practitioner of
acupuncture;
(j) a description of
the applicant's clinical acupuncture training and experience;
(k) a description of the applicant's
acupuncture work experience and, where applicable, supporting
documentation;
(l) an official
transcript sent directly from the applicant's undergraduate college or
university;
(m) an official
transcript sent directly from the applicant's acupuncture school;
(n) where applicable, proof of sufficiency in
the English language or the applicant's signed agreement to use an interpreter,
and the interpreter's credentials, name and address. The interpreter shall be
approved by the Committee.
(2)
Contents of the Application
Form for Re-examination. The Committee's application form for
re-examination in Massachusetts consists of the original application updated on
a form provided by the Committee.
(3)
Contents of the Application
Form for License Renewal. The Committee's renewal application form
will request the following information:
(a)
the applicant's name, date of birth, and home address, mailing address and
principal business address;
(b) a
statement of the applicant's acupuncture training, and any hospital or clinic
affiliations;
(c) a statement of
any disciplinary action taken against the applicant since the last time the
licensee submitted either a renewal application or an initial application for
licensure;
(d) a statement of any
civil litigation related to the practice of acupuncture, or any criminal
litigation commenced against the applicant since the last time the licensee
submitted either a renewal application or an initial application for
licensure;
(e) a statement of other
jurisdictions in which the applicant is licensed to practice;
(f) a description of continuing acupuncture
education courses taken by the applicant since the last time the licensee
submitted either a renewal application or an initial application for licensure,
and evidence of having registered for the courses, such as canceled
checks.
(4)
Contents of an Application Form for a Temporary
License. The Committee's application form for a temporary license
will request the following information:
(a)
the applicant's name, date of birth, and home address and mailing
address;
(b) a statement describing
the applicant's training, work experience, and teaching experience, and an
original copy of the applicant's credentials sent directly from the granting
institution;
(c) where applicable,
a description of the applicant's apprenticeship training and supporting
documentation;
(d) a description of
the clinical courses the applicant will teach or attend, or the acupuncture
educational seminar or program the applicant will lead or attend;
(e) If applicable, the signature of the dean
of the acupuncture school hiring the applicant, and the school's
seal;
(f) If applicable, the
signature of an active licensed acupuncturist who will supervise the
applicant;
(g) the applicant's
social security number;
(h) a
photograph of the applicant adequate for positive identification;
(i) a statement of the applicant's
involvement in civil litigation related to the practice of acupuncture, and any
criminal litigation;
(j) a
statement of any disciplinary action taken against the applicant;
(k) a statement of the other jurisdictions in
which the applicant is or has been licensed to practice acupuncture, including
license numbers and issue dates;
(l) a statement of the applicant's physical
and mental health, including an explanation of any dysfunction impairing him as
a practitioner of acupuncture.
(5)
Applicants for Licensure or
Renewal Who Have Changed Their Names. Each applicant for licensure
or renewal who has been known by a name other than that used on his/her
application shall complete the name change forms used by the Committee to
verify name changes, and shall submit the completed forms along with the
documentation required.
(6)
Translations Required. All documentation submitted in
a language other than English shall be accompanied by a translation into
English prepared at the applicant's expense by a translation service approved
by the Committee. The translator shall attest to the accuracy of the
translation under penalty of perjury.
(7)
Submission of Original
Documents. Each applicant shall have original documents sent
directly from the issuing institution. Under appropriate circumstances, the
Committee may, at its discretion, allow individuals to submit an original
document along with a photocopy, or an affidavit in lieu of an
original document .
(8)
Completed Application Forms.
(a) The Committee considers an application
complete only if it meets the following requirements:
1. It is typewritten or written
legibly;
2. All data, information
and signatures requested are supplied as specified;
3. The proper fee is submitted;
4. The applicant has submitted any additional
material the Committee has requested.
(b) The Committee will return an incomplete
application to the applicant, or notify the applicant of deficiencies. It is
the applicant's responsibility to resubmit the application when it is
complete.
(c) Any application which
is not completed by the applicant within 12 months of initial receipt by the
Committee shall be deemed lapsed. In such circumstances, an applicant must file
a new application, inclusive of proper fee, in order to be considered for
licensure.
