N.H. Admin. Code § Phy 309.03

Current through Register No. 50, December 12, 2024

Section Phy 309.03 - Basic Eligibility Requirements for Temporary Licenses

(a) Applicants for temporary licensure as physical therapists or physical therapist assistants shall:

(1) Have submitted a completed application form for full licensure, pursuant to Phy 304.01 and paid the application fee pursuant to Ahp 301.02;

(2) Pay a temporary license fee of $100;

(3) Hold an unencumbered license from one or more of the states listed in Phy 309.01(a), as evidenced by a letter of good standing sent by that state;

(4) Have committed no acts or omissions which are grounds for disciplinary action in another jurisdiction, or, if such acts have been committed, would be grounds for disciplinary action; and

(5) Complete and submit form "Application for Initial Temporary Licensure and Certification," as adopted on 1/15/2019, as set forth in Ahp 601.04.

(b) Applicants shall place their notarized signature, printed full name, and date of signing on an attestation on the form below the following preprinted statement:

"By Signing this application before the Notary Public/Justice of the Peace I attest to the following:

I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:2, I. I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief.

I also certify that I have read the statute and the rules of the Board and promise that, if I am licensed, I will abide by them. Based on the statute and rules governing the profession for which I am applying I have not committed any acts that would be grounds for disciplinary action in this or any other State.

If I am given a "Temporary License" to practice in the State of New Hampshire I attest to the fact that I am eligible for full licensure meeting all requirements set forth in the Board's Administrative rules including any active in the profession requirements."

(c) The effect of the applicant's notarized signature on the form shall be:

(1) The applicant's acknowledgment that knowingly making a false statement on the application form is a misdemeanor under RSA 641:2, I;

(2) The applicant's certification that:

i. The information provided on all the parts of the application form and in the documents personally submitted to support the application is complete and accurate to the best of the applicant's knowledge and belief; and

ii. The applicant has read the statutes and administrative rules of the board; and

(3) The applicant's promise to abide by the statutes and administrative rules of the board.

N.H. Admin. Code § Phy 309.03

Derived From Volume XXXIX Number 41, Filed October 10, 2019, Proposed by #12864, Effective 9/10/2019, Expires 9/10/2029.