N.H. Admin. Code § Fam 402.04

Current through Register No. 45, November 7, 2024

Section Fam 402.04 - Application Form for Renewal of Certification

(a) The "Mediator-Renewal Application" form for renewal of certification shall:

(1) Be provided by the board on paper, on the board's website, or both; and

(2) Consist of 2 parts, the confidential personal data part of the form and the public information part of the form.

(b) The applicant shall complete the form:

(1) By typing or printing legibly in ink; and

(2) By completing all sections or designating them as not applicable.

(c) On the confidential personal data part of the form the renewal applicant shall supply the following:

(1) The renewal applicant's legal name;

(2) Whether the renewal applicant's name has changed in the past 3 years and, if so, the prior name(s);

(3) The renewal applicant's home mailing address;

(4) The renewal applicant's home telephone number;

(5) The name and address of the renewal applicant's current employer or current place of business; and

(6) The renewal applicant's signature and the date of the signature.

(d) On the public information part of the form the renewal applicant shall supply the following:

(1) The renewal applicant's legal name and certificate number;

(2) The name, mailing address, e-mail address and telephone number of the applicant's mediation business;

(3) Whether any of the information provided to the board in the application submitted for initial certification or for the previous renewal of certification has changed since it was provided;

(4) A list of the courses completed to meet the continuing education requirements set forth in Fam 404.01 showing for each course:

a. The beginning and ending dates of the course;

b. That the course topic was:

1. Recent changes in law and procedure in matters related to divorce, and parental rights and responsibilities;

2. Ethics for mediators;

3. Domestic violence;

4. Mediation skills;

5. Family relationships, child development, impact of divorce and separation on families, substance misuse, and mental health factors in divorce and separation;

6. A specified topic other than the topics listed above;

c. The name of the course provider or sponsor;

d. The number of hours of the course;

e. Whether the course was live; and

f. Whether the course was previously approved by the board;

(5) The number of cases mediated or co-mediated with another certified family mediator per year for the last 3 years, which number of cases shall total no less than 9 cases;

(6) Whether the renewal applicant agrees to abide by 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;

(7) Whether the renewal applicant has enclosed payment of the renewal application fee specified in Fam 304.01(b); and

(8) The renewal applicant's signature and the date of the signature below the following preprinted statement:

"I certify that the information provided on the 2 parts of the renewal application form and the documentation provided to support the application is true, accurate, complete, and unaltered, to the best of the my knowledge and 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."

(e) The renewal applicant's signature shall constitute:

(1) The renewal applicant's certification that the information provided on the 2 parts of the renewal application form and 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 renewal applicant's acknowledgement that:

a. Pursuant to RSA 641:3, knowingly making a false statement on the renewal application form is punishable as a misdemeanor; and

b. Knowingly making a false statement on the renewal application form is grounds for the denial of the application, or grounds for revocation, after notice and the opportunity for a hearing, of renewed certification already issued by the board.

N.H. Admin. Code § Fam 402.04

(See Revision Note at chapter heading for Fam 400), #9672, eff 4-2-10

Amended by Volume XXXVIII Number 41, Filed October 11, 2018, Proposed by #12635, Effective 10/2/2018, Expires 10/2/2028.