Section Hcp 401.03 - Application for License and Registration Renewal An applicant for license or registration renewal shall provide the following information on or with the "Application for Renewal of Audiologist License and Hearing Aid Dealer Registration" form:
(a) The applicant's full name;(b) The applicant's business address and telephone number;(c) The applicant's home address and telephone number;(d) A statement indicating whether the applicant is actively practicing;(e) A statement that the information included in the applicant's initial application has not changed except to the extent it has previously been disclosed to the board or is disclosed and described in an attachment to the application;(f) A statement that the applicant has complied with the applicable continuing education requirements of Hcp 402;(g) A representation that the applicant acknowledges that the provision of false information in the application is a basis for disciplinary action by the board;(h) The applicant's signature; and(i) The date the applicant signed the application.N.H. Admin. Code § Hcp 401.03
#6935, eff 1-29-99, EXPIRED: 1-29-07
New. #9338, eff 12-3-08
Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12112, Effective 2/21/2017, Expires 2/21/2027.