Section Phy 304.02 - Materials Required to Accompany the License Application Form At the time that applicants for initial licensure submit their completed license application form, they shall submit, or arrange for the board to receive, the following materials:
(a) A passport size, 2" x 2", original head-shot photograph taken within the immediately preceding 6 months;(b) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to questions from the application form specified in Ahp 601.01 are in the affirmative;(c) An official transcript showing the relevant degree awarded and the date the degree was awarded;(d) If the applicant is required by Phy 306.04 to take and pass a test of English language proficiency, the applicant's examination scores sent directly to the board by the Educational Testing Service;(e) The applicant's examination scores sent directly to the board by FSBPT;(f) The passing scores on the jurisprudence assessment module sent directly to the board by the Federation of State Boards of Physical Therapy; and(g) If the applicant is required by Phy 305.04 or Phy 305.05 to complete continuing education, documents as described in Phy 407;(h) A resume presenting a chronologically organized account of the applicant's experience in physical therapy for the past 6 years, including: (1) Each separate experience in paid or volunteer work as: a. A clinician in the practice of physical therapy, as defined in RSA 328-A:2, XI;b. A physical therapy educator;c. A physical therapy administrator;d. A physical therapy consultant;e. A student enrolled full time in an advanced physical therapy degree program; orf. A physical therapy researcher;(2) The approximate number of hours spent in each separate experience during each 12-month period of the experience;(3) The name and address of any clinical affiliation, if any, for each experience;(4) The period of each separate experience described by its beginning and ending dates; and(5) The physical address of each experience;(i) Unless the information sought is available only on a website, an official letter of verification sent directly to the board from every state which has issued the applicant a license or other authorization to practice physical therapy stating:(1) Whether the license or other authorization is or was, during its period of validity, in good standing; and(2) Whether any disciplinary action was taken against the license or other authorization to practice;(j) A criminal history records check form and fingerprint card, seeking both a New Hampshire 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;(k) If the federal criminal history records check shows the existence of a criminal record in another state, the applicant shall obtain a detailed criminal record check directly from that state and provide it to the board; and(l) If the conditional licensure described in Phy 307 is applicable to the applicant, the completed supervision form described in Ahp 601.05.N.H. Admin. Code § Phy 304.02
#9233, eff 8-22-08; ss by #10060, eff 12-23-11; ss by #10401, eff 8-23-13
Amended by Volume XXXV, Number 40 filed October 8, 2015, Proposed by #10933, Effective 9/18/2015, Expires9/18/2025.Amended by Volume XXXIX Number 41, Filed October 10, 2019, Proposed by #12864, Effective 9/10/2019, Expires 9/10/2029.