Section Diet 402.03 - Renewal Application Form On a renewal application form provided by the board, an applicant for renewal shall supply the following information:
(b) The street address of the applicant's home;(c) Mailing address, if different from the street address;(f) Home telephone number;(g) Business telephone number;(h) Current New Hampshire Dietetic license number;(i) A list of the activities that the applicant has completed in fulfillment of the continuing professional education requirements of Diet 404.01, including on that list: (1) The name or title of each activity attended, taken, undertaken or presented in fulfillment of the 20 hour continuing professional education credit requirement;(2) Whether the activity has been approved for credit by the CDR;(3) The type of activity attended, taken, undertaken or presented;(4) A statement of the number of credit hours requested for each activity;(5) The date of the activity; and(6) The grade, if any, received for each activity.(j) Whether or not the applicant has ever had an application for a license, certificate or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire denied as the result of a failure to be of good character or on any basis that would constitute cause for denial of a license application under RSA 326-H or the rules of the board;(k) Whether or not the applicant has ever had any certification, registration or approval to practice as a Dietetic revoked in any jurisdiction other than the state of New Hampshire as the result of a failure to be of good character or on any basis that would constitute cause for revocation of a license under RSA 326-H or the rules of the board, unless such revocation was reversed or overturned on appeal or unless such license was reinstated;(l) Whether or not the applicant has ever had been convicted of, or pleaded guilty to, a class A felony that has not been annulled or which has not been reversed or overturned on appeal;(m) Whether or not the applicant has, within the preceding 10 years, been found guilty of malpractice or gross misconduct in practice as a Dietetic in this or any other jurisdiction;(n) Whether or not the applicant has ever been found to have obtained, by fraudulent or deceitful means, a license, certification or other approval to practice as a Dietetic in a jurisdiction other than the state of New Hampshire;(o) Whether or not the applicant has ever committed an act that either caused harm to, or placed at risk, the health, safety or welfare of a person or persons under the applicant's care in the applicant's capacity as a Dietitian;(p) Whether or not the applicant is aware of any basis for a conclusion by the board that he or she is not of good character or should not otherwise be granted a license to practice as a Dietetic in the state of New Hampshire and, if so, an explanation of those reasons;(q) The applicant's signature on a statement preprinted on the form certifying that:(1) The information provided on the renewal application form is true, accurate and complete; and(2) The applicant acknowledges that, pursuant to RSA 641:3, knowingly making a false representation on the renewal application form is punishable as a misdemeanor; and(r) The date of the signature described in (q) above.N.H. Admin. Code § Diet 402.03
#7938, eff 8-23-03; ss by #8336, eff 5-1-05
Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10691, Effective 10/9/2014, Expires10/9/2024.