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
(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
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