New Hampshire Code of Administrative Rules
Rec - Advisory Board of Recreational Therapists
Chapter Rec 400 - CONTINUED STATUS
Part Rec 402 - PROCEDURES FOR RENEWING A LICENSE AND INDICATING A DECISION NOT TO RENEW
Section Rec 402.04 - Licensure Renewal Application Form
Current through Register No. 12, March 21, 2024
(a) The renewal application form shall:
(b) The renewal applicant shall:
(c) On part one of the renewal application form the renewal applicant shall correct as necessary the preprinted home mailing address.
(d) Also on part one of the form the renewal applicant shall list the jurisdictions, other than New Hampshire, where the applicant is currently licensed to practice.
(e) Also on part one of the form using the "yes" and "no" columns provided, indicate whether:
(f) Also on part one of the renewal application form the applicant shall place his or her signature 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."
(g) On part 2 of the form a renewal application form the applicant's:
(h) The renewal applicant shall use the boxes provided to indicate which of the following addresses, if any, the board is permitted to make available to various public entities:
(i) The renewal applicant shall designate by checking one of the appropriate boxes if the applicant wishes to receive correspondence from the board by e-mail or regular mail.
(j) The renewal applicant shall verify his or her social security number and make any necessary corrections to the preprinted number by striking through the incorrect number and writing the corrected number under the following preprinted statement:
"The Governing Board of your profession will deny licensure if you refuse to submit your social security number (SSN). Your professional license will not display your SSN. Your SSN will not be made available to the public.
The Governing Board is required to obtain your social security number for the purpose of child support enforcement and in compliance with RSA 161-B:11, VI-a. This collection of your social security number is mandatory."
(k) Also on confidential part 2 of the renewal application form the renewal applicant shall, indicate using the "yes" and "no" columns provided, indicate whether:
(l) On part 3 of the form the renewal applicant shall:
(m) Also on part 3 of the renewal form the applicant shall use the designated columns to report the following information about each continuing professional education course or professional activity constituting maintenance of continuing competence completed since the issuance of the initial license or the last licensure renewal:
(n) Also on part 3 the renewal applicant shall:
(o) Also on part 2 of the renewal application form the renewal applicant shall, using the "yes" and "no" columns provided, indicate whether the applicant has an ownership interest in any diagnostic or therapeutic service(s) or company(s) as required by RSA 125:25-C.
#9467, eff 5-5-09; ss by #9971, eff 8-9-11; ss by #10223, eff 11-6-12; ss by #10546, eff 3-19-14