Section Mirt 302.02 - Multipart Application Form(a) The multipart "Application for Initial Licensure" form, revised July 2018 shall: (1) Be provided by the board; and(2) Contain 2 parts as follows: a. Part one, which is held confidential by the board; andb. Part 2, which is 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.(d) On confidential part one of the form the applicant shall provide his or her: (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;(e) On part one of the form the applicant shall provide the e-mail or regular mail address at which the applicant wishes to receive notifications from the board.(f) 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 reduction from a position at the applicant's place of employment, or had any privileges limited, suspended, or revoked in any:c. Home health care agency;d. Educational institution; ore. 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.(g) Pursuant to RSA 161-B:11, the applicant shall furnish his or her social security number on part one of the application form.(h) On part 2 of the application form the applicant shall provide: (1) His or her full name;(2) For any 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; andc. The year of the degree or credential earned; and(3) A list of the jurisdictions where the applicant is or has been licensed to practice.(i) 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 diagnostic or therapeutic service(s) or company(ies).(j) 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 641:3, 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."
N.H. Admin. Code § Mirt 302.02
Derived From Volume XXXVIII Number 32, Filed August 9, 2018, Proposed by #12597, Effective 7/31/2018, Expires 7/31/2028.