Section Spe 303.02 - Multipart Application Form for All Applicants(a) The multipart application form shall: (1) Be provided by the board; and(2) Contain 2 parts as follows: a.Part one, which shall be held confidential by the board; andb.Part 2, which shall be available to the public. (b) Applicants for full initial licensure, conditional licensure and provisional licensure shall: (1) Complete the entire form using a keyboard or by printing the information legibly in ink; and(2) Complete all sections of the entire form or designate them as not applicable.(c) On the form such applicant shall designate the initial license applied for by circling the appropriate designation preprinted on the form.(d) On part one of the form the applicant shall provide his or her:(2) Home physical address;(3) Home phone number or personal cell phone number;(4) Home mailing address;(5) Place of employment name, if any;(6) Place of employment mailing address, if any;(7) Place of employment phone number, if any;(8) E-mail address at which the applicant wishes to receive notification from the board;(e) On part one of the form the applicant shall designate, by checking the appropriate box, which address, if any, can be made available to various public entities:(1) Home mailing address;(2) Place of employment mailing address; or(f) Designate by checking in the appropriate box how the applicant wishes to receive notifications from the board, that is, either by e-mail or regular mail.(g) Also on part one of the form the applicant shall indicate using the "yes" and "no" columns provided: (1) Whether the applicant 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 state or jurisdiction;(2) Whether any malpractice claim has been made against the applicant;(3) Whether the applicant has for disciplinary reasons been put on administrative leave, been fired for cause other than staff reductions from a position at the applicant's place of employment, or had any privileges limited, suspended or revoked in any: c.Home health care agency;d.Educational institution; ore.Other professional setting;(4) Whether the applicant has been denied the privilege of taking an examination required for any professional licensure;(5) Whether the applicant has any physical, mental or emotional condition, or any alcohol or substance abuse problem, which could negatively affect the applicant's ability to practice the profession for which licensure is sought; and(6) Whether the applicant engages in any remedial undertaking to alleviate one or more conditions listed in (5) above which could itself negatively affect the applicant's ability to practice the profession for which licensure is sought.(7) Have you committed any act(s) that would violate the laws and/or rules that govern the profession for which you are applying?(h) Pursuant to RSA 161-B:11, VI-a the applicant shall furnish his or her social security number on part one of the application form.(i) On part 2 of the application form the applicant shall provide: (1) His or her full name;(2) For the applicant's undergraduate education and graduate education: a.The name and address of the college, university or other institution;c.The year of the degree earned; andd.The major subject taken in the degree granting program;(3) For any additional education, educational degree or educational credential required to achieve eligibility for initial licensure:a.The name and address of the educational program or institution;b.The degree or other credential earned; andc.The year of the degree or credential earned; and(4) A list of the jurisdictions where the applicant is or has been licensed or certified to practice.(j) On part 2 of the application form the applicant shall indicate by using the "yes" and "no" columns provided: (1) Whether the applicant has been found guilty or entered a plea of no contest to any felony or misdemeanor;(2) Whether the applicant has ever been the subject of any disciplinary action by any professional licensing authority;(3) Whether the applicant has ever been denied a license or other authorization to practice in any state or jurisdiction;(4) Whether the applicant has ever surrendered a license or other authorization to practice issued by any state or jurisdiction in order to avoid or settle disciplinary charges; and(5) Pursuant to RSA 125:25-c, whether the applicant has any ownership interest in any diagnostic or therapeutic service(s) company(ies), and, if the answer is "yes", the applicant shall attach a list of all diagnostic or therapeutic services provided by each company.(k) Also on part 2 of the form the applicant shall place his or her notarized signature, printed full name and the date of signing below the following preprinted statement: "I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:2, I. I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read the statute and the rules of the Board and promise that, if I am licensed, I will abide by them."
N.H. Admin. Code § Spe 303.02
(See Revision Note at chapter heading for Spe 300) #9125, eff 4-5-08; ss by #10019, eff 11-5-11
Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10682, Effective 10/4/2014, Expires10/4/2024.Amended by Volume XXXV Number 32, Filed August 13, 2015 , Proposed by #10906, Effective 8/7/2015, Expires8/7/2025.