Current through Register No. 12, March 21, 2024
The information required by Plc 308.05(b)(1) shall be as
follows:
(a) The applicant's
profession and the license number and expiration date of the license;
(b) For individuals, 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
social security number, as required by
RSA
161-B:11, VI-a and
42 U.S.C.
666(a)(13);
(4) The applicant's designated email address,
home physical address, and home mailing address, if different;
(5) The applicant's home or other personal
telephone number;
(6) The name,
physical address, and telephone number of the applicant's office or other place
of business;
(7) If the applicant
routinely practices in more than one location, the name of each such location
and, for each:
a. The business address, and
telephone number; and
b. Whether
the applicant is an employee, a subtenant subletting space, an independent
contractor, or the owner of the business;
(8) 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; and
(9) Any other profession-specific information
required by applicable law, such as proof of certification by, or registration
with, a regional or national credentialing organization, to the extent not
otherwise covered by this section;
(c) For entities, 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 location address
in New Hampshire 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;
(d) Identification of all states where the
applicant is currently licensed and, for each, the date of most recent
licensure and status of the license;
(e) A "yes" or "no" answer to the following
questions regarding the applicant's background and character, provided that
"not previously reported" shall not include anything not required to be
submitted by Plc 304.03(e):
(1) Whether during
the past 27 months or not previously reported, the applicant has been found
guilty of or entered a plea of no contest to any felony or
misdemeanor;
(2) Whether during the
past 27 months or not previously reported, the applicant has been the subject
of any disciplinary action by any professional licensing authority;
(3) Whether during the past 27 months or not
previously reported, the applicant has been denied a license or other
authorization to practice in any jurisdiction;
(4) Whether during the past 27 months or not
previously reported, the applicant has surrendered a license or other
authorization to practice issued by any jurisdiction in order to avoid or
settle disciplinary charges;
(5)
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;
(6) Whether during
the past 27 months or not previously reported, any malpractice claim has been
made against the applicant;
(7)
Whether during the past 27 months or not previously reported, the applicant
has, for disciplinary reasons, been put on administrative leave, been fired for
cause other than staff reductions from a position at the applicant's place of
employment, or had any privileges limited, suspended or revoked in any
professional setting;
(8) Whether
during the past 27 months or not previously reported, the applicant has been
denied the privilege of taking an examination required for any professional
licensure; and
(9) Whether during
the past 27 months or not previously reported, the applicant has committed any
act(s) that would violate the laws and/or rules that govern the practice of the
profession in which the applicant is licensed;
(f) 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; and
(g)
For applicants in any health care field, 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.