Current through Register No. 12, March 21, 2024
The applicant shall identify the profession for which the
application is being filed and indicate whether the applicant is an individual
or an entity, and then provide the following information:
(a) If the applicant is an individual, the
following:
(1) The applicant's full legal
name, including any suffix such as "Jr." or "III", and any name(s) under which
the applicant holds or has held a professional license;
(2) The applicant's date of birth by month,
day, and year;
(3) The applicant's
gender assigned at birth, to be used solely for purpose of workforce data
analysis by New Hampshire employment security;
(4) The applicant's social security number,
as required by RSA
161-B:11, VI-a and
42 U.S.C.
666(a)(13);
(5) The applicant's home physical address by
street name and number, apartment number if applicable, municipality, county,
state, zip code, and country if not the U.S., and home mailing address if
different;
(6) The applicant's home
or other personal telephone number;
(7) The applicant's designated email
address;
(8) The name, physical
address, and telephone number of the applicant's anticipated office or other
place of business, if known;
(9)
Whether the applicant speaks English as the primary language and, if not, the
applicant's primary language and other secondary languages;
(10) Whether the applicant is on active
military duty or is the spouse of an individual who is on active military duty,
and whether the applicant is applying for facilitated licensure;
(11) Whether the applicant intends to
practice in New Hampshire more than 50% of the time, whether in-person or by
telehealth;
(12) If specific
training or a specific degree is required by applicable law, the name of the
educational institution that provided the training or degree required and the
date the training was completed or degree was received; and
(13) Any other profession-specific
information required by applicable law, to the extent not otherwise covered by
this section;
(b) If the
applicant is an entity, the following:
(1) The
applicant's full legal name as shown on the document(s) that created the entity
and each name under which the applicant does business in New
Hampshire;
(2) The type of entity
the applicant is, such as a corporation, limited liability corporation,
professional association, partnership, or other form;
(3) The entity's date and state of
formation;
(4) The applicant's
primary physical address in New Hampshire by street name and number, suite
number if any, municipality, county, and zip code, and New Hampshire mailing
address if different;
(5) The
applicant's main telephone number;
(6) The applicant's designated email
address;
(7) The name, telephone
number, and email address of the individual authorized by the applicant to sign
the application and the name, telephone number, and email address of each
individual authorized by the applicant to interact with the OPLC regarding the
application and any license issued based on the application, if other than the
authorized signer; and
(8) Any
additional information required for entities by applicable law;
(c) Identification of each
jurisdiction in which the applicant has applied for, holds, or has held a
license to practice in the same profession as the license being applied for
and, if required by applicable law, any other profession for which the
applicant holds or has held a license, and for each, the license number, date
initially licensed, date most recently licensed, and the status in each
jurisdiction such as in good standing, expired, suspended, revoked, or denied
renewal;
(d) If the applicant is
applying for an initial license in New Hampshire based on reciprocity and is
licensed in more than one other jurisdiction, identification of which
jurisdiction the applicant believes has requirements for licensure that are
equivalent to, or greater than, those established by applicable law;
(e) A "yes" or "no" answer to the following
questions relating to background and character:
(1) Whether the applicant is now or has any
reason to believe that the applicant will soon be the subject of a disciplinary
proceeding, settlement agreement, or consent decree undertaken or issued by a
professional licensing board of any jurisdiction;
(2) Whether any malpractice claim has been
made against the applicant within the past 10 years;
(3) Whether the applicant has, for
disciplinary reasons, been put on administrative leave, been fired for cause
other than staff reduction from a position at the applicant's place of
employment, or had any privileges limited, suspended, or revoked in any
professional setting within the past 10 years;
(4) Whether the applicant has been denied the
privilege of taking an examination required for any professional licensure
within the past 10 years;
(5)
Whether the applicant has committed any act(s) within the past 10 years that
would violate the laws or rules that govern the profession for which
application is being made;
(6)
Whether the applicant has ever been found guilty of or entered a plea of no
contest to any felony that is related to professional practice;
(7) Whether the applicant has been found
guilty of or entered a plea of no contest to, within the past 10 years, any
felony that is not related to professional practice, or any
misdemeanor;
(8) Whether the
applicant has been the subject of any disciplinary action by any professional
licensing authority within the past 10 years;
(9) Whether the applicant has, within the
past 10 years, been denied a license or other authorization to practice in any
jurisdiction; and
(10) Whether the
applicant has, within the past 10 years, surrendered a license or other
authorization to practice issued by any jurisdiction in order to avoid or
settle disciplinary charges;
(f) For applicants in any health care
profession, whether the applicant has an ownership interest in any diagnostic
or therapeutic service(s) or company(ies), and if so the name and address of
each company and the specific diagnostic or therapeutic services provided by
the company, to comply with
RSA
125:25-c; and
(g) Whether the applicant consents to the
disclosure to third parties of:
(1) For
individuals, any or all of the applicant's contact information; or
(2) For entities, the entity's designated
email address.
