Section 5.05 - Application Provisions(1)Contents of the Application Form for a Full License. The Committee's application form for a full license will request the following information: (a) the applicant's name; date and place of birth; and home address, mailing address and principal business address;(b) the applicant's social security number;(c) a photograph of the applicant adequate for positive identification;(d) a written statement asserting that the applicant is of good moral character. This statement must be executed by someone who is unrelated to the applicant and who has known the applicant well and for a minimum of three years, preferably an acupuncturist licensed to practice in Massachusetts;(e) a statement of the applicant's involvement in civil litigation related to the practice of acupuncture, and any criminal litigation;(f) a statement of any disciplinary action taken against the applicant;(g) a statement of the other jurisdictions in which the applicant is or has been licensed to practice acupuncture, including license numbers and issue dates;(h) a statement of the results of any acupuncture licensure examination the applicant has taken;(i) a statement of the applicant's physical and mental health, including an explanation of any dysfunction impairing him as a student or practitioner of acupuncture;(j) a description of the applicant's clinical acupuncture training and experience;(k) a description of the applicant's acupuncture work experience and, where applicable, supporting documentation;(l) an official transcript sent directly from the applicant's undergraduate college or university;(m) an official transcript sent directly from the applicant's acupuncture school;(n) where applicable, proof of sufficiency in the English language or the applicant's signed agreement to use an interpreter, and the interpreter's credentials, name and address. The interpreter shall be approved by the Committee.(2)Contents of the Application Form for Re-examination. The Committee's application form for re-examination in Massachusetts consists of the original application updated on a form provided by the Committee.(3)Contents of the Application Form for License Renewal. The Committee's renewal application form will request the following information: (a) the applicant's name, date of birth, and home address, mailing address and principal business address;(b) a statement of the applicant's acupuncture training, and any hospital or clinic affiliations;(c) a statement of any disciplinary action taken against the applicant since the last time the licensee submitted either a renewal application or an initial application for licensure;(d) a statement of any civil litigation related to the practice of acupuncture, or any criminal litigation commenced against the applicant since the last time the licensee submitted either a renewal application or an initial application for licensure;(e) a statement of other jurisdictions in which the applicant is licensed to practice;(f) a description of continuing acupuncture education courses taken by the applicant since the last time the licensee submitted either a renewal application or an initial application for licensure, and evidence of having registered for the courses, such as canceled checks.(4)Contents of an Application Form for a Temporary License. The Committee's application form for a temporary license will request the following information: (a) the applicant's name, date of birth, and home address and mailing address;(b) a statement describing the applicant's training, work experience, and teaching experience, and an original copy of the applicant's credentials sent directly from the granting institution;(c) where applicable, a description of the applicant's apprenticeship training and supporting documentation;(d) a description of the clinical courses the applicant will teach or attend, or the acupuncture educational seminar or program the applicant will lead or attend;(e) If applicable, the signature of the dean of the acupuncture school hiring the applicant, and the school's seal;(f) If applicable, the signature of an active licensed acupuncturist who will supervise the applicant;(g) the applicant's social security number;(h) a photograph of the applicant adequate for positive identification;(i) a statement of the applicant's involvement in civil litigation related to the practice of acupuncture, and any criminal litigation;(j) a statement of any disciplinary action taken against the applicant;(k) a statement of the other jurisdictions in which the applicant is or has been licensed to practice acupuncture, including license numbers and issue dates;(l) a statement of the applicant's physical and mental health, including an explanation of any dysfunction impairing him as a practitioner of acupuncture.(5)Applicants for Licensure or Renewal Who Have Changed Their Names. Each applicant for licensure or renewal who has been known by a name other than that used on his/her application shall complete the name change forms used by the Committee to verify name changes, and shall submit the completed forms along with the documentation required.(6)Translations Required. All documentation submitted in a language other than English shall be accompanied by a translation into English prepared at the applicant's expense by a translation service approved by the Committee. The translator shall attest to the accuracy of the translation under penalty of perjury.(7)Submission of Original Documents. Each applicant shall have original documents sent directly from the issuing institution. Under appropriate circumstances, the Committee may, at its discretion, allow individuals to submit an original document along with a photocopy, or an affidavit in lieu of an original document .(8)Completed Application Forms.(a) The Committee considers an application complete only if it meets the following requirements: 1. It is typewritten or written legibly;2. All data, information and signatures requested are supplied as specified;3. The proper fee is submitted;4. The applicant has submitted any additional material the Committee has requested.(b) The Committee will return an incomplete application to the applicant, or notify the applicant of deficiencies. It is the applicant's responsibility to resubmit the application when it is complete.(c) Any application which is not completed by the applicant within 12 months of initial receipt by the Committee shall be deemed lapsed. In such circumstances, an applicant must file a new application, inclusive of proper fee, in order to be considered for licensure.