Current through Register No. 12, March 21, 2024
(a)
The "Mediator-Renewal Application" form for renewal of certification shall:
(1) Be provided by the board on paper, on the
board's website, or both; and
(2)
Consist of 2 parts, the confidential personal data part of the form and the
public information part of the form.
(b) The applicant shall complete the form:
(1) By typing or printing legibly in ink;
and
(2) By completing all sections
or designating them as not applicable.
(c) On the confidential personal data part of
the form the renewal applicant shall supply the following:
(1) The renewal applicant's legal
name;
(2) Whether the renewal
applicant's name has changed in the past 3 years and, if so, the prior
name(s);
(3) The renewal
applicant's home mailing address;
(4) The renewal applicant's home telephone
number;
(5) The name and address of
the renewal applicant's current employer or current place of business;
and
(6) The renewal applicant's
signature and the date of the signature.
(d) On the public information part of the
form the renewal applicant shall supply the following:
(1) The renewal applicant's legal name and
certificate number;
(2) The name,
mailing address, e-mail address and telephone number of the applicant's
mediation business;
(3) Whether any
of the information provided to the board in the application submitted for
initial certification or for the previous renewal of certification has changed
since it was provided;
(4) A list
of the courses completed to meet the continuing education requirements set
forth in
Fam
404.01 showing for each course:
a. The beginning and ending dates of the
course;
b. That the course topic
was:
1. Recent changes in law and procedure in
matters related to divorce, and parental rights and responsibilities;
2. Ethics for mediators;
3. Domestic violence;
4. Mediation skills;
5. Family relationships, child development,
impact of divorce and separation on families, substance misuse, and mental
health factors in divorce and separation;
6. A specified topic other than the topics
listed above;
c. The name
of the course provider or sponsor;
d. The number of hours of the
course;
e. Whether the course was
live; and
f. Whether the course was
previously approved by the board;
(5) The number of cases mediated or
co-mediated with another certified family mediator per year for the last 3
years, which number of cases shall total no less than 9 cases;
(6) Whether the renewal applicant agrees to
abide by the "Model Standards of Practice for Family and Divorce Mediation"
developed by The Symposium on Standards of Practice and finalized on August 5,
2000, and available as noted in Appendix II;
(7) Whether the renewal applicant has
enclosed payment of the renewal application fee specified in
Fam
304.01(b); and
(8) The renewal applicant's signature and the
date of the signature below the following preprinted statement:
"I certify that the information provided on the 2 parts of
the renewal application form and the documentation provided to support the
application is true, accurate, complete, and unaltered, to the best of the my
knowledge and belief; and I acknowledge that, pursuant to
RSA 641:3,
knowingly making a false statement on the application form is punishable as a
misdemeanor and grounds for the denial of the application, or grounds for
revocation, after notice and the opportunity for a hearing, of certification
already issued by the board."
(e) The renewal applicant's signature shall
constitute:
(1) The renewal applicant's
certification that the information provided on the 2 parts of the renewal
application form and the documentation provided to support the application is
true, accurate, complete, and unaltered, to the best of the applicant's
knowledge and belief; and
(2) The
renewal applicant's acknowledgement that:
a.
Pursuant to
RSA 641:3,
knowingly making a false statement on the renewal application form is
punishable as a misdemeanor; and
b.
Knowingly making a false statement on the renewal application form is grounds
for the denial of the application, or grounds for revocation, after notice and
the opportunity for a hearing, of renewed certification already issued by the
board.
(See Revision Note at chapter heading for Fam 400), #9672,
eff 4-2-10
