New Hampshire Code of Administrative Rules
Hcp - Board of Hearing Care Providers
Chapter Hcp 300 - INITIAL LICENSURE AND REGISTRATION
Part Hcp 301 - INITIAL LICENSURE AS AN AUDIOLOGIST
Section Hcp 301.02 - Application for Audiologist License

(a) The applicant's name, home address and telephone number;

(b) The applicant's date of birth;

(c) A description of the applicant's education;

(d) A list of any other audiology licenses held by the applicant in other jurisdictions, including each state in which licensure is held;

(e) The length of time the applicant has been practicing as a licensed audiologist;

(f) Whether the applicant has ever been refused an audiology license by any licensing body, and if so, the name of the board, the date of denial, and the reasons for denial;

(g) Whether the applicant has ever been convicted of a felony or misdemeanor that has not been annulled by a court of competent jurisdiction and, if so, the name of the court, the detail of the offense, the date of conviction and the sentence imposed;

(h) Documentation that the applicant has met all of the educational requirements as detailed in the requirements as set forth in Hcp 301.03;

(i) A certification separately signed by the applicant indicating that the application is true, correct, and complete to the best of the applicant's knowledge and belief;

(j) The applicant's Social Security number as required by RSA 161-B:11, VI-a;

(k) The applicant's signature and date of signature; and

(l) Payment in the amount specified in Hcp 306.01 in cash, or by check or money order made payable to "Treasurer, State of New Hampshire."