Section Ch 403.05 - Reinstatement Application Form(a) The "Application for Reinstatement of Licensure" form, effective April 29, 2021 shall:(1) Be supplied by the board; and(2) Contain the following preprinted statement: "I herewith apply for a license to practice chiropractic in accordance with RSA 316-A and the rules of the New Hampshire Board of Chiropractic Examiners. I am the applicant identified in the application. I will notify the board in writing within 30 days of any change in the information provided in the application, even after the application has been granted and a license issued. I consent to the board's use for all purposes of the mailing and electronic addresses provided to the board in the application or thereafter. The information provided on the application form and the documentation provided to support the application are, to the best of my knowledge and belief, true, accurate, complete and unaltered. I acknowledge that, pursuant to RSA 641:3, I, the knowing making of a false statement on the application form is punishable as a misdemeanor, and, should I knowingly provide the board with any false, inaccurate, incomplete or altered information or documentation, the board has the authority to deny the application or, after a hearing, to take disciplinary action against any license issued to me."
(b) The effect of the reinstatement applicant's notarized signature on the application form shall be: (1) The applicant's acknowledgement that knowingly making a false statement on the application form is a misdemeanor under RSA 641:2, I;(2) The applicant's certification that: a. The information provided on all of the parts of the application form and in the documents personally submitted to support the application is complete and accurate to the best of the applicant's knowledge and belief; andb. The applicant has read the statutes and administrative rules of the board; and(3) The applicant's promise to abide by the statutes and administrative rules of the board.N.H. Admin. Code § Ch 403.05
Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12107, Effective 2/21/2017, Expires8/20/2017.Amended by Volume XXXVII Number 50, Filed December 14, 2017, Proposed by #12431, Effective 12/8/2017, Expires 12/8/2027.Amended by Volume XLII Number 6, Filed February 10, 2022, Proposed by #13327, Effective 1/21/2022, Expires 1/21/2032