Section Saf-C 5904.03 - Provider License Application Statement of CertificationBy signing the provider license application, the applicant shall certify that:
(a) The information provided in the application is complete, truthful, and correct under penalties of unsworn falsification pursuant to RSA 641:3;(b) He or she has not been convicted or found guilty of an offense pursuant to RSA 153-A:13, I;(c) He or she complies with RSA 153-A and these rules;(d) He or she understands any material falsification of information shall result in license denial, suspension, or revocation, in accordance with Saf-C 5922.03 or Saf-C 5922.05 and may be grounds for a misdemeanor conviction pursuant to RSA 641:3;(e) He or she has not been subject to limitation, suspension from, or under revocation or probation of the ability to practice in a health care occupation or voluntarily surrendered a health care license in any state or to any agency authorizing the right to work; and(f) If the applicant is unable to certify compliance with Saf-C 5904.03(b) to 5904.03(e) the applicant shall provide official documentation that fully describes the offense, current status, and disposition of the case.N.H. Admin. Code § Saf-C 5904.03
(See Revision Note at chapter heading for Saf-C 5900) #7690, eff 5-21-02, EXPIRED: 5-21-10
New. #9779-A, eff 9-8-10
Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12790, Effective 5/24/2019, Expires 5/24/2029.