Section 16-85-46 - Certification application(a) An application for certification shall be made under oath on a form to be provided by the board. The form may require the applicant to provide: (1) The appropriate fees including the application fee which shall not be refunded;(2) The applicant's full name;(3) Evidence of graduation from a board approved school or training program;(4) Evidence of passage of the national certification examination developed by the National Commission on Certification of Physician's Assistants (NCCPA);(5) Evidence of current NCCPA certification;(6) Information regarding any conviction of any crime which has not been annulled or expunged;(7) A completed Federation Discipline Report from the Federation of State Medical Boards;(8) If applicable, evidence of any certifications held or once held in other jurisdictions indicating the status of the certification and documenting any disciplinary action;(9) Any other information the board may require to investigate the applicant's qualifications for certification;(10) A statement signed by the licensed physician or group of physicians, as the case may be, stating that the physician or group of physicians will direct and supervise the physician assistant and that the physician assistant will be considered the agent of the physician or group of physicians; and(11) The name of the employer.(b) An application for a temporary certificate shall be made under oath on a form to be provided by the board. The form shall require the applicant to provide verification from the NCCPA that the applicant is scheduled to take the next scheduled examination and items listed in subsection (a) above with the exception of items (4) and (5). Graduation from a board approved school or training program shall have occurred within twelve months of the date of application.(c) It shall be the applicant's responsibility to furnish any information and documentation requested by the board. In the event of any change of information provided, the applicant shall notify the board of any change within thirty days of any change.(d) Every application and all references shall be signed by the applicant or the person attesting to the applicant's education, experience, employment, and reputation.[Eff 6/30/81; am and comp 7/27/87; comp 10/28/89; comp 8/25/90; am and comp 12/22/97] (Auth: HRS §§ 453-5.1, 453-5.3) (Imp: HRS § 453-5.3)The amended version of this section by Hawaii Administrative Rules Listing of Filings, 2015-01, June, eff.6/22/2015 is not yet available.