N.H. Code Admin. R. Opt 301.02 - Application Form

Current through Register Vol. 42, No. 14, April 7, 2022

Applicant's for licensure shall provide, or cause to be provided, the following on a "Application for Licensure" form, effective August 2017, supplied by the board:

(a) The applicant's full name and address;
(b) Birth date, place of birth, and social security number;
(c) The name(s), address(es) and degree(s) of all colleges or junior colleges attended at either an undergraduate or graduate level, and an official transcript showing each degree awarded;
(d) The name(s), address(es), and degree(s) of all optometry colleges attended, and an official transcript showing each degree awarded;
(e) A statement as to whether the applicant has passed the National Board of Examiners in Optometry (NBEO) Exam, parts I, II and III, and if so, a statement that a request has been made for the NBEO to forward a certified copy of the score report directly to the board as required by Opt 301.05(a);
(f) If the applicant passed the NBEO exam prior to December 1, 1993, proof of passage of the separate Therapeutic Management of Ocular Disease (TMOD) exam given by the NBEO pursuant to Opt 301.05(d);
(g) A statement as to whether the applicant has passed the New England Regional Clinical Optometric Assessment Testing Service (NERCOATS) exam, or its successor, and if so, a statement that a request has been made for the testing authority to forward a certified score report directly to the board pursuant to Opt 301.06(c);
(h) Original letters of reference from 2 practicing doctors of optometry, which identifies the name and address of each such doctor;
(i) A copy of a valid certificate verifying that the applicant has completed a program that certifies ability to perform cardio-pulmonary resuscitation (CPR) for adult, child and infant life support;
(j) If the applicant graduated from an accredited college of optometry prior to January 1, 1993, a statement as to whether the applicant has successfully completed a 105 hour post-graduate course that meets the requirements of Opt 301.03(c) and if so, a statement that a request has been made for the college of optometry to provide a certificate of completion showing fulfillment of all the requirements of Opt 301.03(c);
(k) A statement as to whether the applicant is currently or has been, but is not now, licensed to practice optometry in any state or other jurisdiction, and if so:
(1) The type of license;
(2) The issuing jurisdiction;
(3) The dates of the license; and
(4) The reason the applicant no longer holds the license, if applicable.
(l) A statement as to whether the applicant has ever been refused a license by any optometry licensing body, and if so, the name of the board, the date of denial and the reasons for denial;
(m) A statement as to whether the applicant has ever had a license to practice optometry suspended or revoked in any jurisdiction and, if yes, an explanation of such suspension or revocation;
(n) A statement as to whether the applicant has ever been convicted of a felony or misdemeanor that has not been annulled, and, if so, the name of the court, the details of the offense, the date of conviction and the sentence imposed;
(o) A recent, unretouched 2" x 2" photograph of the applicant;
(p) A statement that cash, a check or money order, made out to the Treasurer, State of New Hampshire in the amount of the application fee required by Opt 303.01(a) is enclosed with the application;
(q) A declaration that the applicant shall practice ethically and within the rules and laws governing the practice of optometry;
(r) A declaration that the applicant shall comply with all of the rules of the board, specifically including those governing renewals and requirements for continuing education, Opt 400;
(s) A declaration that the applicant is the person identified in the application and that all information contained in the application is true and correct; and
(t) The date and signature of the applicant.

Notes

N.H. Code Admin. R. Opt 301.02

(See Revision Note at part heading for Opt 100) #5839, eff 6-17-94, EXPIRED: 6-17-00

New. #7433, eff 1-25-01, EXPIRED: 1-25-09

New. #9558, eff 10-6-09

Amended by Volume XXXVII Number 41, Filed October 12, 2017, Proposed by #12383, Effective 9/16/2017, Expires 9/16/2027.

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