Section Plc 304.03 - Information Required for Initial License Application On the application form identified in Plc 304.01(a)(1), the applicant shall identify the profession for which the application is being filed and indicate whether the applicant is an individual or an entity, and then provide the following information:
(a) If the applicant is an individual, the following:(1) The applicant's full legal name, including any suffix such as "Jr." or "III", and any name(s) under which the applicant holds or has held a professional license;(2) The applicant's date of birth by month, day, and year;(3) The applicant's social security number or other U.S. taxpayer identification number, as required by RSA 161-B:11, VI-a and 42 U.S.C. 666(a)(13);(4) The applicant's home physical address by street name and number, apartment number if applicable, municipality, county, state, zip code, and country if not the U.S., and home mailing address if different;(5) The applicant's home or other personal telephone number;(6) The applicant's designated email address;(7) The name, physical address, and telephone number of the applicant's anticipated office or other place of business, if known;(8) Whether the applicant speaks English as the primary language and, if not, the applicant's primary language and other secondary languages;(9) Whether the applicant is on active military duty or is a military spouse, and whether the applicant is applying for facilitated licensure;(10) The following information, to be used solely for purpose of workforce data analysis, provided that "prefer not to answer" shall be an acceptable response to any question:b. Applicant's race or ethnicity, including information regarding Hispanic, Latino/a, or Spanish origin;c. Highest level of education, whether or not related to the profession in which licensure is being sought;d. Where the applicant completed the education program or degree, as applicable, that first qualified the applicant for the license being applied for, provided that if the program or degree was completed on-line, identify where the on-line program was housed;e. Relative to the applicant's employment status, whether the applicant is:1. Actively working in a position that requires the license being applied for;2. Actively working in a position in the same profession that does not require this license;3. Actively working in a position in a different profession;4. Not currently working; orf. Relative to the applicant's employment plans for the next 2 years, whether the applicant intends to:1. Increase hours in a field related to this license;2. Decrease hours in a field related to this license;3. Seek employment in a field unrelated to this license;6. Not sure or plans unknown;g. Identification of the specialty, field, or area of practice in which the applicant spends the most professional time;h. Whether the applicant uses telehealth to deliver services to patients;i. The state in which the applicant's primary practice is located, if applicable;j. The 5-digit zip code of the applicant's primary practice location, if applicable;k. Relative to the applicant's current employment arrangement at their principal practice location, whether the applicant is:1. Self-employed or a consultant;4. In temporary employment or Locum Tenens;l. In the applicant's primary employment or practice, whether the applicant's primary role is that of: 2. Clinical practitioner;3. Faculty or other educator;(11) For applicants in any health care field:a. Identification of the practice setting at the applicant's primary practice location;b. What population groups the applicant provides services to;c. An estimate of the number of hours per week the applicant spends at their primary practice location; andd. An estimate of the number of hours per week the applicant spends in direct patient care;(12) For applicants in any health care field, whether the applicant intends to practice in New Hampshire more than 50% of the time, whether in-person or by telehealth;(13) If specific training or a specific degree is required by applicable law, the name of the educational institution that provided the training or degree required and the date the training was completed or degree was received; and(14) Any other profession-specific information required by applicable law, to the extent not otherwise covered by this section;(b) If the applicant is an entity, the following:(1) The applicant's full legal name as shown on the document(s) that created the entity and each name under which the applicant does business in New Hampshire;(2) The type of entity the applicant is, such as a corporation, limited liability corporation, professional association, partnership, or other form;(3) The entity's date and state of formation;(4) The employer identification number or other federal tax ID number assigned to the applicant by the U.S. Internal Revenue Service;(5) The applicant's primary physical address in New Hampshire by street name and number, suite number if any, municipality, county, and zip code, and New Hampshire mailing address if different;(6) The applicant's main telephone number;(7) The applicant's designated email address;(8) The name, telephone number, and email address of the authorized signer and the name, telephone number, and email address of each contact individual, if other than the authorized signer;(9) Such information as is required by applicable law on partners, officers, directors, and similar individuals having responsibility for or control over the applicant; and(10) Any additional information required for entities by applicable law;(c) Identification of each jurisdiction in which the applicant has applied for, holds, or has held a license to practice in the same profession as the license being applied for and, if required by applicable law, any other profession for which the applicant holds or has held a license, and for each, the license number, date initially licensed, date most recently licensed, and the status in each jurisdiction such as in good standing, expired, suspended, revoked, or denied renewal;(d) If the applicant is applying for an initial license in New Hampshire based on endorsement, and is licensed in more than one other jurisdiction, identification of which jurisdiction the applicant believes has requirements for licensure that are substantially similar to, or greater than, those established by applicable law;(e) A "yes" or "no" answer to the following questions relating to background and character: (1) Whether the applicant is now or 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 jurisdiction;(2) Whether any malpractice claim has been made against the applicant within the past 10 years;(3) Whether the applicant has, for disciplinary reasons, been put on administrative leave, been fired for cause other than staff reduction from a position at the applicant's place of employment, or had any privileges limited, suspended, or revoked in any professional setting within the past 10 years;(4) Whether the applicant has been denied the privilege of taking an examination required for any professional licensure within the past 10 years;(5) Whether the applicant has committed any act(s) within the past 10 years that would violate the laws or rules that govern the profession for which application is being made;(6) Whether the applicant has ever been found guilty of or entered a plea of no contest to any felony that is related to professional practice;(7) Whether the applicant has been found guilty of or entered a plea of no contest to, within the past 10 years, any felony that is not related to professional practice, or any misdemeanor;(8) Whether the applicant has been the subject of any disciplinary action by any professional licensing authority within the past 10 years;(9) Whether the applicant has, within the past 10 years, been denied a license or other authorization to practice in any jurisdiction; and(10) Whether the applicant has, within the past 10 years, surrendered a license or other authorization to practice issued by any jurisdiction for any reason;(f) Whether the applicant has a DEA registration number and, if so, what the number is;(g) Whether the applicant stores, administers, or dispenses controlled drugs in a setting that is not regulated under RSA 318 relative to pharmacists and pharmacies and if so, the location of the activity;(h) For applicants in any health care profession, whether the applicant has an ownership interest in any diagnostic or therapeutic service(s) or company(ies), and if so the name and address of each company and the specific diagnostic or therapeutic services provided by the company, to comply with RSA 125:25-c; and(i) Whether the applicant consents to the disclosure to third parties of:(1) For individuals, any or all of the applicant's contact information; or(2) For entities, the entity's designated email address.N.H. Admin. Code § Plc 304.03
Derived from Number 15, Filed April 13, 2023, Proposed by #13606, Effective 5/1/2023, Expires 5/1/2033.Amended by Number 24, Filed June 13, 2024, Proposed by #13955, Effective 5/3/2024, Expires 5/3/2034 (see Revision Note #2 at chapter heading for Plc 300).