Section Nat 302.03 - Two-Part Application Form(a) Applicants for initial licensure shall complete, sign, and date a 2-part application form provided by the board.(b) The information entered on both parts of the application form shall be typewritten or legibly printed in ink.(c) On the first part of the application form applicants shall provide the following information: (1) First name, middle initial, and last name;(2) Date and place of birth;(3) Business or other mailing address by name of business, if any, street number and name, city or town, state, and zip code;(4) Business telephone number; and(5) With respect to naturopathic medical education: a. The name and location of the institution(s);b. The dates of attendance; and(d) On the first part of the application form under the heading "Other Information" applicants shall indicate, using the "yes" and "no" boxes provided, whether: (1) They have ever been licensed or otherwise authorized to practice naturopathic medicine in any state, the District of Columbia, any territory, or any foreign country;(2) They have ever been refused a professional license or other authorization to practice naturopathic medicine by a regulatory body of any state, country or other regulatory jurisdiction;(3) They have ever had a professional license or other authorization to practice naturopathic medicine revoked or suspended by a regulatory body of any state, country, or other regulatory jurisdiction;(4) They have had disciplinary action other than action reportable under paragraphs (2) and (3) taken against them by any state, country, or other regulatory jurisdiction;(5) They have ever entered into a settlement agreement or consent decree to resolve a complaint of misconduct or a disciplinary charge;(6) Any of their professional licenses are presently the subject of a disciplinary proceeding, settlement agreement or consent decree undertaken or issued by any professional licensing authority in any jurisdiction;(7) In the past 10 years, any disciplinary action has been taken against them by any hospital or other health care facility, or international, national, state, or local professional association;(8) A malpractice claim or a malpractice law suit has been brought against them within the last 10 years;(9) They have ever been denied certification by NCCAOM or ACNO;(10) Their NCCAOM or ACNO certification has ever been suspended or revoked; and(11) They have ever been convicted of a felony or misdemeanor.(e) The applicant shall sign and date the first part of the application form below the following statement preprinted on the form: (1) The information provided on both parts of the application form and the documentation provided to support the application are true, accurate, complete and unaltered; and(2) The applicant acknowledges that, pursuant to RSA 641:3, the knowing making of a false statement on the application form is punishable as a misdemeanor."(f) The applicant's signature as set forth in (e) above shall constitute the applicant's acknowledgement of his or her understanding that any untrue, inaccurate, incomplete, or altered information made knowingly on either part of the application form or included in the supporting materials is grounds for punishment pursuant to RSA 641:3.(g) On the second part of the application form applicants shall provide: (1) Their home addresses by street number and name, city or town, state, and zip code; and(2) Their home telephone numbers.(h) On the second part of the application form applicants shall indicate, using the "yes" and "no" boxes provided, whether: (1) They are now being, anticipate being, or have ever been, investigated for possible misconduct by a regulatory body of any state or country or other regulatory jurisdiction;(2) They anticipate that any of their professional licenses soon will be the subject of a disciplinary proceeding, settlement agreement, or consent decree undertaken or issued by any professional licensing authority in any jurisdiction;(3) They have ever voluntarily surrendered a license or other authorization to practice naturopathic medicine, or allowed such a license or authorization to lapse, to avoid disciplinary investigation or action;(4) They are now being, or have in the past 10 years been, investigated and disciplined for possible misconduct by a hospital or other health care facility, or international, national, state, or local professional association;(5) They have any physical, mental, addictive or other condition that negatively affects their ability to practice naturopathic medicine;(6) They have any physical, mental, addictive, or other condition for which continuing remedial or therapeutic action is required to ensure their continuing ability to practice naturopathic medicine; and(7) Since graduation from high school they have ever been denied the privilege of taking or finishing an examination or been accused of cheating or improper conduct during an examination.(i) Applicants shall also complete and submit, as part of their application, a board provided "Application Checklist" form, effective March 2017.N.H. Admin. Code § Nat 302.03
#6380, eff 11-26-96, EXPIRED: 11-26-04
New. #8374, eff 6-18-05
Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12176, Effective 5/17/2017, Expires 5/17/2027.