New Hampshire Code of Administrative Rules
Plc - Executive Director, Office of Professional Licensure and Certification
Chapter Plc 300 - LICENSURE OF REGULATED PROFESSIONS
Part Plc 313 - LICENSURE BY ENDORSEMENT
Section Plc 313.04 - Information Required for Initial License Application

Universal Citation: NH Admin Rules Plc 313.04

Current through Register No. 12, March 21, 2024

. The applicant shall identify the profession for which the application is being filed and then provide the following information:

(a) 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;

(b) The applicant's date of birth by month, day, and year;

(c) The applicant's social security number, as required by RSA 161-B:11, VI-a and 42 U.S.C. 666(a)(13);

(d) The applicant's gender assigned at birth, to be used solely for purpose of workforce data analysis by New Hampshire employment security;

(e) 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;

(f) The applicant's home or other personal telephone number;

(g) The applicant's designated email address;

(h) The name of the jurisdiction in which the applicant is licensed that the applicant believes has requirements that are substantially similar to New Hampshire's requirements;

(i) For applicants in any health care field:

(1) Whether the applicant intends to practice in New Hampshire more than 50% of the time, whether in-person or by telehealth; and

(2) Whether the applicant has an ownership interest in any diagnostic or therapeutic service(s) or company(ies) and if so, the name, address, and specific diagnostic or therapeutic service offered by each company;

(j) Whether the applicant is on active military duty or is a military spouse, and whether the applicant is applying for facilitated licensure; and

(k) Whether the applicant consents to the disclosure to third parties of any or all of the applicant's contact information.

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