(a) The
reinstatement application form shall be the "Application for Reinstatement of
Licensure and Certification" dated September 3, 2015. The reinstatement
application form shall be provided by the board and available by submitting a
request for the application form on the board's website,
www.nh.gov/alliedhealth.
(b) To apply for reinstatement, the applicant
shall:
(1) Provide the information on the
"Application for Reinstatement of Licensure or Certification" form dated June
24, 2015 to the board;
(2) Sign and
date 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."
(c) The effect of the reinstatement
applicant's notarized signature on the application form shall be:
(1) The applicant's acknowledgement that
knowingly making a false statement on the application form is a misdemeanor
under RSA
641:2, I;
(2) The applicant's certification that:
a. The information provided on all of the
parts of the application form and in the documents personally submitted to
support the application is complete and accurate to the best of the applicant's
knowledge and belief; and
b. The
applicant has read the statutes and administrative rules of the board;
and
(3) The applicant's
promise to abide by the statutes and administrative rules of the
board.
Notes
N.H. Admin. Code §
Rec 403.05
Amended by
Volume
XXXVII Number 2, Filed January 12, 2017, Proposed by #12072,
Effective 12/23/2016, Expires
12/23/2026.
