1. (a) An applicant for recertification after lapse of his or her certificate shall:

   1. (1) Legibly complete the “Recertification After Lapse of the Certificate to Practice Midwifery” application form, effective 10/2016, furnished by the midwifery council;
   2. (2) Complete all sections of the recertification application form or designate them as not applicable;
   3. (3) Date the recertification application form; and
   4. (4) Sign the recertification application form in accordance with (b) below.

2. (b) An applicant for recertification shall:

   1. (1) Place his or her signature below the following statement preprinted on the recertification application form:

      "The information provided on the recertification application form and the documentation provided to support the recertification application are, to the best of my knowledge and belief, true, accurate, complete and unaltered. I acknowledge that, pursuant to RSA 641:3, the knowing making of a false statement on the recertification application form is punishable as a misdemeanor"; and

   2. (2) Place the date next to the signature.

3. (c) The effect of the signature shall be that the applicant for recertification:

   1. (1) States that, to the best of his or her knowledge and belief, the information provided on the recertification application form and the documentation provided to support the recertification application are accurate, complete and unaltered; and
   2. (2) Acknowledges that, pursuant to RSA 641:3, the knowing making of a false statement on the recertification application form is punishable as a misdemeanor.

Source. #9089, eff 2-20-08, EXPIRED: 2-20-16 New. #11095, INTERIM, eff 5-12-16, EXPIRED: 11-8-16 New. #12040, eff 11-10-16