Current through Register No. 12, March 21, 2024
(a) The
multipart application form shall:
(1) Be
provided by the board; and
(2)
Contain 2 parts as follows:
a. Part one, which
shall be held confidential by the board; and
b. Part 2, which shall be available to the
public.
(b)
The applicant shall:
(1) Complete the entire
form using a keyboard or by printing the information legibly in ink;
and
(2) Complete all sections of
the entire form or designate them as not applicable.
(c) On part one of the form, the applicant
shall designate the initial license applied for by circling the appropriate
designation preprinted on the form.
(d) On part one of the form, the applicant
shall provide his or her:
(1) Full
name;
(2) Home physical
address;
(3) Home phone number or
personal cell phone number;
(4)
Home mailing address;
(5) Place of
employment name, if any;
(6) Place
of employment mailing address, if any;
(7) Place of employment phone number, if
any;
(8) E-mail address at which
the applicant wishes to receive correspondence from the board;
(9) Date of birth; and
(10) Place of birth.
(e) On part one of the form, the applicant
shall designate, by checking the appropriate box, which address, if any, can be
made available to the public for purchase:
(1)
Home mailing address;
(2) Place of
employment mailing address; or
(3)
None.
(f) Designate by
checking in the appropriate box if the applicant wishes to receive
notifications from the board by e-mail or regular mail.
(g) Also on part one of the form, the
applicant shall indicate using the "yes" and "no" columns provided:
(1) Whether the applicant 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 state or jurisdiction;
(2) Whether any malpractice claim has been
made against the applicant;
(3)
Whether 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:
a. Hospital;
b. Health care setting;
c. Home health care agency;
d. Educational institution; or
e. Other professional setting;
(4) Whether the applicant has been
denied the privilege of taking an examination required for any professional
licensure;
(5) Whether the
applicant has any physical, mental or emotional condition, or any alcohol or
substance abuse problem, which could negatively affect the applicant's ability
to practice the profession for which licensure is sought;
(6) Whether the applicant engages in any
remedial undertaking to alleviate one or more conditions listed in (5) above
which could itself negatively affect the applicant's ability to practice the
profession for which licensure is sought; and
(7) Whether the applicant has committed any
act(s) that would violate the laws or rules that govern the profession for
which he or she is applying.
(h) Pursuant to
RSA
161-B:11, VI-a the applicant shall furnish
his or her social security number on part one of the application
form.
(i) On part 2 of the
application form the applicant shall provide:
(1) His or her full name;
(2) For the applicant's undergraduate
education and graduate education:
a. The name
and address of the college, university or other institution;
b. The degree earned;
c. The year of the degree earned;
and
d. The major subject taken in
the degree-granting program;
(3) For any additional education, educational
degree or educational credential required to achieve eligibility for initial
licensure:
a. The name and address of the
educational program or institution;
b. The degree or other credential earned;
and
c. The year of the degree or
credential earned; and
(4) A list of the jurisdictions where the
applicant is or has been licensed to practice.
(j) On part 2 of the application form the
applicant shall indicate by using the "yes" and "no" columns provided:
(1) Whether the applicant has been found
guilty of or entered a plea of no contest to any felony or
misdemeanor;
(2) Whether the
applicant has ever been the subject of any disciplinary action by any
professional licensing authority;
(3) Whether the applicant has ever been
denied a license or other authorization to practice in any state or
jurisdiction;
(4) Whether the
applicant has ever surrendered a license or other authorization to practice
issued by any state or jurisdiction in order to avoid or settle disciplinary
charges; and
(5) Whether the
applicant has a full or partial ownership interest in any business providing
services in the allied health professional field for which the applicant seeks
to be licensed.
(k) Also
on part 2 of the form the applicant shall place his or her notarized signature,
printed full name and the date of signing below the following preprinted
statement:
"I acknowledge that knowingly making a false statement on
this application form is a misdemeanor under
RSA
641:2, I. I certify that the information I
have provided on all parts of the application form and in the documents that I
have personally submitted to support my application is complete and accurate to
the best of my knowledge and belief. I also certify that I have read the
statute and the rules of the Board and promise that, if I am licensed, I will
abide by them."
#9038, eff 11-28-07; ss by #9446, eff 4-7-09; ss by #9970,
eff 8-9-11; ss by #10545, eff 3-19-14
