New Hampshire Code of Administrative Rules
Ch - Board of Chiropractic Examiners
Chapter Ch 400 - CONTINUED STATUS
Part Ch 402 - RENEWAL OF LICENSE
Section Ch 402.06 - Signature to Statement Required

An applicant for renewal licensure shall sign and date the following statement preprinted on the renewal application form:

"I herewith apply for renewal of my license to practice chiropractic. I am the applicant identified in the renewal application. I will notify the board in writing within 30 days of any change in the information provided in the renewal application, even after the application has been granted and my license has been renewed. I consent to the board's use for all purposes of the mailing and electronic addresses provided to the board in the renewal application or thereafter.

The information provided on the renewal application form and the documentation provided to support the renewal application are, to the best of my knowledge and belief, true, accurate, complete and unaltered. I acknowledge that, pursuant to RSA 641:3, I, the knowing making of a false statement on the renewal application form is punishable as a misdemeanor, and, should I knowingly provide the board with any false, inaccurate, incomplete or altered information or documentation, the board has the authority to deny the renewal application or, after a hearing, to take disciplinary action against the renewed license issued to me.

I have read and understand RSA 316-A and the current administrative rules of the New Hampshire Board of Chiropractic Examiners."

#8739, eff 10-11-06