New Hampshire Code of Administrative Rules
Acp - Board of Acupuncture Licensing
Chapter Acp 300 - LICENSE REQUIREMENTS, APPLICATIONS AND FEES
Part Acp 301 - APPLICATION PROCEDURE
Section Acp 301.02 - Application Form

Universal Citation: NH Admin Rules Acp 301.02

Current through Register No. 40, October 3, 2024

The applicant shall supply, or cause to be supplied, the following on or with the "Acupuncture Initial License Application" form:

(a) Full legal name, as well as:

1. Any previously used names that might appear on supporting documentation; and

2. If applicable, name as it is written in Chinese, Korean, or other foreign language;

(b) Residence and business addresses and telephone numbers;

(c) Date of birth;

(d) Social Security number pursuant RSA 161-B:11;

(e) Email address;

(f) A list of colleges and universities the applicant attended, dates of attendance, and degrees, if any received, supported by one of the following:

(1) An official transcript from the college or university which granted the degree; or

(2) In the case of an undergraduate degree from a college or university outside the United States, supporting documents pursuant to Acp 302.03(c);

(g) If the applicant is applying for a waiver of the degree requirement, the supporting documentation pursuant to Acp 302.03(b);

(h) A list of acupuncture schools attended, dates attended, date of graduation and degree or certificate awarded, supported by official transcripts from all acupuncture schools or colleges attended;

(i) If the applicant is applying for a waiver of the post-secondary acupuncture college requirement, the supporting documentation pursuant to Acp 302.05;

(j) A list of all other states and countries in which the applicant is currently licensed, registered, or otherwise allowed to practice acupuncture, dates of issue and expiration, and the license or certificate numbers. Documentation of the status of all current acupuncture licenses held shall be sent directly from the issuing state or country;

(k) A list of other states and countries in which the applicant was ever previously licensed, registered, or otherwise allowed to practice acupuncture, including dates of issue and expiration;

(l) A list of all states and countries in which the applicant was previously or is currently licensed, registered, or otherwise allowed to practice a healing art other than acupuncture, including dates of issue and expiration;

(m) Information regarding the applicant's certification by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) supported by documentation of certification status sent to the board directly from the NCCAOM or downloaded from the official NCCAOM website, including the date of initial certification;

(n) Disclosure, and explanation where applicable, of the following information:

(1) If any malpractice claim has ever been made against the applicant, regardless of whether a lawsuit was filed in relation to the claim;

(2) If the applicant has ever been denied an acupuncture license, certificate, or registration anywhere for any reason;

(3) If the applicant ever had employment or appointment in a hospital, clinic, or other health care facility suspended, or resigned from a health care facility in lieu of being subject to a disciplinary action;

(4) If the applicant has any formal disciplinary charges pending or if any disciplinary action has been taken against the applicant by any acupuncture or medical board, any health care facility, or any professional acupuncture association;

(5) If the applicant ever voluntarily surrendered a license to practice acupuncture or other healing art in lieu of facing disciplinary action;

(6) If the applicant has, at any time, been convicted of a crime involving violence, abuse, fraud, dishonesty, or drugs;

(7) If the applicant ever had a professional license in a field other than acupuncture revoked, suspended, or otherwise terminated on disciplinary grounds, or if any disciplinary actions are currently pending against the applicant in relation to any professional license held; and

(8) If the applicant has ever had or currently has an emotional disturbance or mental illness, an organic illness, or addictive disorder which impaired their ability to practice acupuncture or to function as an acupuncture student. If so, the applicant shall describe treatment received and the outcome of such treatment;

(o) A statement of the applicant's successful completion of the Clean Needle Technique Course supported by documentation of such directly from the NCCAOM or the Council of Colleges of Acupuncture and Herbal Medicine (CCAHM);

(p) A statement of good professional character from 3 persons other than relatives of the applicant, who have known the applicant for at least 3 years, at least one of whom shall be an acupuncturist, licensed in this state or in another jurisdiction; and

(q) The applicant's signature on the following statement:

I hereby certify that all statements made in this application and all information and documentation submitted in connection with this application are, to the best of my knowledge, true, accurate, complete, and unaltered. I understand that misstatements and omissions of material facts may be cause for denial of this application, or for suspension or revocation of a license, or other appropriate disciplinary action.

In the case that my application is approved and an acupuncture license is issued to me, I hereby agree to comply with all laws and administrative rules pertaining to the practice of acupuncture in New Hampshire. I understand that this includes the requirement to use only sterile disposable one-use needles, and to use Clean Needle Technique. I understand that I must follow the New Hampshire Code of Ethics for acupuncturists and the NCCAOM Code of Ethics for acupuncturists.

#7081, eff 8-26-99; ss by #7872, eff 4-14-03; ss by #10004, INTERIM, eff 9-22-11, EXPIRES: 3-20-12; New. #10158, eff 6-27-12

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