Section Phy 304.04 - Materials Required to Accompany the License Application Form At the time that applicants for initial licensure submit their completed license application forms, they shall submit, or arrange for the board to receive, the following materials:
(a) A recent passport size, 2" x 2", original head-shot photograph;(b) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to questions (f)(1) through (f)(6) on confidential part one of the application form is in the affirmative;(c) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to questions (i)(1) through (i)(5) on part 2 of the application form is in the affirmative;(d) In the case of US-educated applicants who did not submit an official transcript at the time of application to take the examination, an official transcript submitted as required by Phy 303.01(c)(1) showing the relevant degree awarded and the date the degree was awarded;(e) If the applicant is required by Phy 306.03 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;(f) If the applicant took the national examination for the purpose of licensure in another state or took it a second time for the purpose of complying with Phy 305.04(b)(2)a., the applicant's examination scores sent directly to the board by FSBPT;(g) The passing scores on the jurisprudence exam sent directly to the board by the Federation of State Boards of Physical Therapy; and(h) If the applicant is required by Phy 305.04 or Phy 305.05 to complete continuing education, documents as described in Phy 407;(i) A resume presenting a chronologically organized account of the applicant's experience in physical therapy since the completion of the academic program, including: (1) Each separate experience in paid or volunteer work as: a. A direct care-giver in physical therapy;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 period of each separate experience described by its beginning and ending dates;(3) The physical address of each experience; and(4) The approximate number of hours spent in each separate experience during each 12-month period of the experience;(j) 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;(k) An original, not a photocopy, of a criminal offender record report: (1) Issued by each state where the applicant has resided or been licensed within the past 6 years, providing that such state will: a. Send the report to the board; or b. To the applicant for forwarding to the board;(2) Covering the applicant under his or her name and any aliases; and (3) Dated within the 6 months preceding the application for licensure; and(l) If the conditional licensure described in Phy 307 is applicable to the applicant, the completed supervision form described in Phy 307.05.N.H. Admin. Code § Phy 304.04
#9233, eff 8-22-08; ss by #9429, eff 3-19-09; ss by #9653, eff 2-5-10; ss by #9869, eff 2-18-11; ss by #10060, eff 12-23-11; ss by #10401, eff 8-23-13
Amended byVolume XXXIV Number 50, Filed December 11, 2014, Proposed by #10724, Effective 11/22/2014, Expires11/22/2024.The amended version of this section by New Hampshire Register Volume 37, Number 06, eff. 1/20/2017 is not yet available.