Section Fam 302.03 - Application Form(a) The "Mediator-Initial Application" form shall be provided by the board and consist of 2 parts, the confidential personal data part of the form and the public information part of the form.(b) On the confidential personal data part of the form the applicant shall supply the following: (1) The applicant's legal name;(2) Any other names used by the applicant within the past 5 years, the time period in which such other names were used and the reason for using such other names;(3) The applicant's home address;(4) The applicant's home telephone number;(5) The applicant's home e-mail address, if the applicant has one and wishes to provide it;(6) The date and place of the applicant's birth;(7) The name or place of business of the applicant's current employer and the address of the applicant's current employer, if the applicant has a current employer;(8) A list of the applicant's employers or places of business during the 5 years preceding the date of the application, if the applicant was employed or in business during that period;(9) Pursuant to RSA 161-B:11, the applicant's Social Security number;(10) A list of the names and addresses of the individuals who will send letters of recommendation directly to the board, to include the names and addresses of all individuals who supervised the internship hours whether or not the individual provides a reference; and(11) The applicant's signature and the date of the signature.(c) On the public information part of the form the applicant shall supply the following: (1) The applicant's legal name;(2) The applicant's mediation business name, if any;(3) The applicant's mediation business address, telephone, and e-mail address;(4) A description of any setting in which the applicant provides mediation services, whether: a. A non-profit organization;b. A solo private practice;d. A 2-person private practice;e. A group private practice;g. Another setting described by the applicant;(5) The name and address of any mediation programs or organizations with which the applicant is currently affiliated or has been affiliated during the 5 years preceding the date of the application;(6) The name and address of the educational institution(s) at which the applicant received the education required by Fam 303.02 and the dates of the applicant's attendance there;(7) The name and address of the provider of the core mediation training required by Fam 303.03(a) and the applicant's dates of attendance at such training;(8) The name and address of the provider of the mediation training specific to New Hampshire required by Fam 303.03(a)(1)b. and the applicant's dates of attendance at such training;(9) The name and address of the provider of the domestic violence training required by Fam 303.03(a)(1)c. and the applicant's dates of attendance at such training;(10) Whether the applicant has completed the applicable internship requirements of Fam 303.07;(11) If the applicant seeks to qualify as a family law practitioner or mental health practitioner as described in Fam 303.08:a. A description of his or her practice in the last 3 years;b. A list of the jurisdictions in which the applicant has, in the last 10 years, either practiced family law or practiced as a psychologist, pastoral psychotherapist, clinical social worker, clinical mental health counselor, or marriage and family therapist; andc. A statement that at least one third of the time of the applicant's practice involved divorce matters or matters of parental rights and responsibilities;(12) Whether the applicant agrees to abide by both Fam 800 and the "Model Standards of Practice for Family and Divorce Mediation" developed by The Symposium on Standards of Practice and finalized on August 5, 2000, and available as noted in Appendix II;(13) A description of the applicant's professional experience as a mediator other than internship, if any;(14) Whether the applicant holds or has ever held a mediator's certificate or other authorization to practice mediation issued by any domestic or foreign government;(15) Whether the applicant holds or has ever held a license, certificate, or other authorization to practice a profession other than mediation issued by any domestic or foreign government;(16) If the answer to (14) or (15) above is affirmative:a. The type of professional practice authorized;b. The name and address of the licensing, certifying, or authorizing authority;c. The beginning and ending dates of validity of the license, certificate, or authorization; andd. Whether the applicant's license, certification, or approval to practice has ever been subject to disciplinary sanctions;(17) Whether there are any disciplinary charges pending against a license, certification or authorization to practice a profession issued to the applicant;(18) Whether the applicant has: a. Engaged in conduct resulting in a finding of abuse as further described in Fam 303.09(d) or been a party to any court case in which the applicant has been found in contempt;b. Had a professional license or certification revoked under the circumstances described in Fam 303.09(e);c. Been convicted as an adult of a crime as described in Fam 303.09(f); ord. Been convicted as an adult and within the past 10 years of a misdemeanor as described in Fam 303.09(g);(19) Whether the applicant has enclosed a check, payable to the State of New Hampshire, in the amount of the fee specified in Fam 304.01(a); and(20) The applicant's signature and the date of the signature below a preprinted statement as follows: "I certify that the information provided on the 2 parts of the application form and the documentation provided to support the application is true, accurate, complete, and unaltered, to the best of my knowledge a belief; and I acknowledge that, pursuant to RSA 641:3, knowingly making a false statement on the application form is punishable as a misdemeanor and grounds for the denial of the application, or grounds for revocation, after notice and the opportunity for a hearing, of certification already issued by the board."
(d) The applicant's signature on the form shall constitute:(1) The applicant's certification that the information provided on the 2 parts of the application form and in the documentation provided to support the application is true, accurate, complete, and unaltered, to the best of the applicant's knowledge and belief; and(2) The applicant's acknowledgement that:a. Pursuant to RSA 641:3, knowingly making a false statement on the application form is punishable as a misdemeanor; andb. Knowingly making a false statement on the application form is grounds for the denial of the application, or grounds for revocation, after notice and the opportunity for a hearing, of certification already issued by the board.N.H. Admin. Code § Fam 302.03
#5609, eff 4-6-93, EXPIRED: 4-6-99
New. #7716, INTERIM, eff 6-22-02, EXPIRED: 12-19-02
New. #7917, eff 7-11-03; ss by #8719, eff 11-1-06; ss by #8930, eff 7-4-07; ss by #9674, eff 4-2-10 (see Revision Note at chapter heading for Fam 300)
Amended by Volume XXXVIII Number 41, Filed October 11, 2018, Proposed by #12634, Effective 10/2/2018, Expires 10/2/2028.