Section Mirt 402.05 - Multipart Licensure Renewal Application Form(a) The "Renewal Application" form shall be provided by the board; and(b) The renewal applicant shall: (1) Complete the entire renewal application form using a keyboard or by printing legibly in ink; and(2) Complete all sections of the entire renewal application form or designate them as not applicable.(c) The applicant shall provide the following on the form:(2) Home physical address;(3) Home phone number or personal cell phone number;(5) Home mailing address;(6) Place of employment name , if any;(7) Place of employment mailing address;(8) Place of employment phone number;(9) E-mail address at which the applicant wishes to receive correspondence from the board; and(10) A list of the jurisdictions, other than New Hampshire, where the applicant is currently licensed to practice.(d) The applicant for renewal shall answer the following questions by using the "yes" and "no" columns provided, to indicate whether:(1) During the past 27 months, or if not previously reported, the applicant has been found guilty or entered a plea of no contest to any felony or misdemeanor;(2) During the past 27 months, or if not previously reported, the applicant has been the subject of any disciplinary action by any professional certifying or registering authority;(3) During the past 27 months, or if not previously reported, the applicant has been denied a license or other authorization to practice in any state or jurisdiction; and(4) During the past 27 months, or if not previously reported, the applicant has surrendered a license or other authorization to practice issued by any state or jurisdiction in order to avoid or settle disciplinary charges.(5) 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;(6) During the past 27 months, or if not previously reported, any malpractice claim has been made against the applicant;(7) During the past 27 months, or if not previously reported, the applicant has for disciplinary reasons been put on administrative leave, been fired for cause other than staff reduction from a position at your 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;(8) During the past 27 months, or if not previously reported the applicant has been denied the privilege of taking an examination required for any professional licensure; (9) During the past 27 months, or if not previously reported 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; and(10) During the past 27 months, or if not previously reported, the applicant has committed any act(s) that would violate the laws or rules that govern the profession for which he or she is a applying.(e) 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 correct number under the following preprinted statement: "The Board 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 Board is required to obtain your social security number for the purpose of child support enforcement and in compliance with RSA 161-B:11. This collection of your social security number is mandatory."
(f) The renewal 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."
N.H. Admin. Code § Mirt 402.05
Derived from Volume XL Number 33, Filed August 13, 2020, Proposed by #13075, Effective 7/24/2020, Expires 7/24/2030.