New Hampshire Code of Administrative Rules
Ch - Board of Chiropractic Examiners
Chapter Ch 300 - LICENSING REQUIREMENTS
Part Ch 302 - APPLICATION PROCEDURE
Section Ch 302.04 - Information Required by the Application Form

(a) The applicant's full name, physical address, mailing address, telephone number and e-mail address, if any;

(b) The applicant's social security number pursuant to RSA 161-B:11, VI-a, date of birth, height, weight, eye color and hair color;

(c) The applicant's national provider identifier, if known;

(d) The applicant's physical address for the past 5 years;

(e) Whether the applicant has any physical, mental, or other condition or disability affecting the applicant's ability to practice chiropractic;

(f) Whether the applicant has any physical, mental or other condition or disability for which continuing remedial or therapeutic action is required to ensure the applicant's continuing ability to practice chiropractic;

(g) Whether the applicant uses alcohol or controlled or non-controlled drugs in a manner affecting the applicant's ability to practice chiropractic;

(h) Whether the applicant has ever been convicted of a felony or misdemeanor;

(i) If any answer to (e), (f), (g), or (h) is affirmative, a summary statement explaining the answer and specifying as applicable:

(j) For each post- secondary educational institution attended by the applicant, regardless of degrees earned, the following information:

(k) For any chiropractic college attended, its name, address, the dates attended by the applicant, and the date of the applicant's graduation;

(l) Whether the applicant currently holds, or has previously held, any professional license, certification or registration to practice any method of healing other than chiropractic;

(m) If the answer to (l) is affirmative, the type of license(s) held and the issuing jurisdiction or state;

(n) Whether the applicant currently holds, or has previously held, any license to practice chiropractic;

(o) For every license to practice chiropractic held in the past or at present:

(p) Whether the applicant has ever been refused:

(q) For every refusal of a license, certification or registration as described in paragraph (p) above:

(r) Whether the applicant has ever had any disciplinary action taken by any other jurisdiction against the applicant's chiropractic license or any other professional license, certification or registration;

(s) Whether, during the past 10 years there have been, or whether there are now, complaints pending, or investigations being conducted, in connection with any professional license, certification or registration previously or currently held by the applicant;

(t) Whether, to the best of the applicant's knowledge, there are currently pending any malpractice claims, settlements or judgments;

(u) Whether, in the past 10 years, any malpractice claims have been settled or resolved, or malpractice judgments issued, against the applicant; and

(v) If any answer to (r), (s), (t), or (u) is affirmative, a detailed written explanation of the circumstances.