New Hampshire Code of Administrative Rules
Diet - Board of Licensed Dietitians
Chapter Diet 400 - CONTINUED STATUS
Part Diet 402 - RENEWAL OF LICENSES
Section Diet 402.03 - Renewal Application Form

(a) Full name;

(b) The street address of the applicant's home;

(c) Mailing address, if different from the street address;

(d) Business address;

(e) Email address;

(f) Home telephone number;

(g) Business telephone number;

(h) Current New Hampshire Dietetic license number;

(i) A list of the activities that the applicant has completed in fulfillment of the continuing professional education requirements of Diet 404.01, including on that list:

(j) Whether or not the applicant has ever had an application for a license, certificate or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire denied as the result of a failure to be of good character or on any basis that would constitute cause for denial of a license application under RSA 326-H or the rules of the board;

(k) Whether or not the applicant has ever had any certification, registration or approval to practice as a Dietetic revoked in any jurisdiction other than the state of New Hampshire as the result of a failure to be of good character or on any basis that would constitute cause for revocation of a license under RSA 326-H or the rules of the board, unless such revocation was reversed or overturned on appeal or unless such license was reinstated;

(l) Whether or not the applicant has ever had been convicted of, or pleaded guilty to, a class A felony that has not been annulled or which has not been reversed or overturned on appeal;

(m) Whether or not the applicant has, within the preceding 10 years, been found guilty of malpractice or gross misconduct in practice as a Dietetic in this or any other jurisdiction;

(n) Whether or not the applicant has ever been found to have obtained, by fraudulent or deceitful means, a license, certification or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire;

(o) Whether or not the applicant has ever committed an act that either caused harm to, or placed at risk, the health, safety or welfare of a person or persons under the applicant's care in the applicant's capacity as a Dietitian;

(p) Whether or not the applicant is aware of any basis for a conclusion by the board that he or she is not of good character or should not otherwise be granted a license to practice as a Dietetic in the state of New Hampshire and, if so, an explanation of those reasons;

(q) The applicant's signature on a statement preprinted on the form certifying that:

(r) The date of the signature described in (q) above.