New Hampshire Code of Administrative Rules
Hcp - Board of Hearing Care Providers
Chapter Hcp 400 - LICENSE RENEWAL AND FEES
Part Hcp 401 - LICENSURE AND REGISTRATION RENEWALS
Section Hcp 401.03 - Application for License and Registration Renewal

(a) The applicant's full name;

(b) The applicant's business address and telephone number;

(c) The applicant's home address and telephone number;

(d) A statement indicating whether the applicant is actively practicing;

(e) A statement that the information included in the applicant's initial application has not changed except to the extent it has previously been disclosed to the board or is disclosed and described in an attachment to the application;

(f) A statement that the applicant has complied with the applicable continuing education requirements of Hcp 402;

(g) A representation that the applicant acknowledges that the provision of false information in the application is a basis for disciplinary action by the board;

(h) The applicant's signature; and

(i) The date the applicant signed the application.