N.H. Admin. Code § Mtec 304.01

Current through Register No. 50, December 12, 2024

Section Mtec 304.01 - Application

(a) Persons wishing to register as a medical technician in New Hampshire shall apply to the board by submitting the following:

(1) A completed application on the "Application For Registration of Medical Technicians" form provided by the board, which contains the information specified by Mtec 304.01 (b);

(2) Criminal history records check form and fingerprint card, seeking both a NH and a federal records check in accordance with the procedure specified by the NH Department of Safety at Saf-C 5700, Operation of the Central Repository: Criminal Records with the required fee;

(3) A 2 inch by 2 inch passport quality photograph taken within 90 days of the date of the application; and

(4) The fee as required by RSA 328-:6,I.

(b) The applicant shall supply the following information on the "Application For Registration of Medical Technicians" form:

(1) Legal name, as it should appear on the registration;

(2) Any other name used, including a maiden name, if different from (1) above;

(3) Home street and mailing address, and telephone number;

(4) Place of current employment, with business address and telephone number;

(5) Personally identifying information of the applicant, to include:

a. Birthplace;

b. Date of birth;

c. Sex;

d. Social security number, pursuant to RSA 161-B: 11,VII-a; and

e. Current personal email address, if applicable;

(6) The applicant's intended or current occupation, profession, or job;

(7) A list of all places where the applicant was employed at any time during the 10 year period ending upon the date of the application, together with:

a. The name and address of the employer;

b. Dates that the employment began and ended; and

c. The reason for leaving the employment;

(8) A "Yes" or "no" answer to the following questions:

a. "Have you ever received disciplinary action against any license, certification or registration in any state or jurisdiction, including reprimand, probation, suspension, revocation, education or practice stipulations, fines or voluntary surrender?"

b. "Are you currently, or have you previously been impaired by or diverted any chemical substances that impaired your ability to practice?"

c. "Have you ever been convicted of a felony under the laws of the United States or any state or any offense involving moral turpitude?"; and

(9) The applicant's signature on a statement, which shall be signed, dated and acknowledged before a notary public or justice of the peace that:

a. The information and documentation provided on all parts of the application form and submitted to support the application is complete and accurate to the best of the applicant's information and belief; and

b. Knowingly making a false statement in the application is a misdemeanor under RSA 641:2, I; and

c. The applicant has read RSA 328-I and the rules of the board, and promises that if registered, will abide by them.

(c) In addition to the application, the applicant shall attach a letter of explanation for any "yes" answer to any of the questions listed in (b)(8) above.

N.H. Admin. Code § Mtec 304.01

Derived From Volume XXXVI Number 19, Filed May 12, 2016, Proposed by #11091-B, Effective 5/5/2016, Expires 5/5/2026.

Amended by Volume XXXIX Number 06, Filed February 7, 2019, Proposed by #12710, Effective 1/11/2019, Expires 1/11/2029.