(a) A registrant whose registration has expired may apply for reinstatement of the registration on the “Application for Reinstatement of Registration” form supplied by the board, and provide the following information:

1. (1) Legal name, as it should appear on the registration;
2. (2) Any other name used, including a maiden name, if different from (1) above;
3. (3) Former registration number, if any;
4. (4) Home street and mailing address;
5. (5) Telephone number and e-mail address;
6. (6) The applicant’s intended or current occupation, profession or job;

7. (7) A list of all places where the applicant has been employed at any time since registration lapsed and ending upon the date of the application, together with:

   1. a. The name and address of the employer;
   2. b. Dates that the employment began and ended; and
   3. c. The reason for leaving the employment;

8. (8) A “Yes” or “no” answer to the following questions relating to circumstances occurring since the registration has lapsed or which have not previously been disclosed to the Board:

   1. a. “Have you ever received disciplinary action against any license, certification or registration in any state or jurisdiction, including a reprimand, probation, suspension, revocation, education or practice stipulations, fines or voluntary surrender?”
   2. b. “Are you currently, or have you previously been impaired by or diverted any chemical substances that impaired your ability to practice?”
   3. c. “Have you ever been convicted of a felony under the laws of the United States or any state or any offense involving moral turpitude?”

9. (9) The applicant's signature on a statement, which shall be signed, dated and acknowledged before a notary public or justice of the peace that:

   1. a. The information and documentation provided on all parts of the application form and submitted to support the application is complete and accurate to the best of the applicant’s information and belief;
   2. b. Knowingly making a false statement in the application is a misdemeanor under RSA 641:2, I; and
   3. c. The applicant has read RSA 328-I and the rules of the board, and promises that if registered, will abide by them.

(b) The request for reinstatement shall be accompanied by the following:

1. (1) The fee established by the board pursuant to Mtec 305.01; and

2. (2) A letter of explanation for any “yes” answer provided in response to the questions described in (a)(8) above.

   Source. #11091-B, eff 5-5-16; ss by #12710, eff 1-11-19

   APPENDIX

   Rule

   Specific State Statute which the Rule Implements

   Mtec 401.01- 401.04

   RSA 328:I:4; 328-I:8-9

   Mtec 401.01

   RSA 126-A:10-a,I-a(a)

   Mtec 401.02

   RSA 328-I:8

   Mtec 401.03

   RSA 328-I:9

   Mtec 401.04

   RSA 328-I:4; RSA 328-I:7