Applicants for telepass license shall provide, or arrange for the OPLC to receive, the following documents supporting their application:

1. (a) A passport size, 2" x 2", original head-shot photograph taken withing 90 days of the submission of the application;

2. (b) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to questions required by Plc 304.03(e) are in the affirmative providing all additional documents listed below with the application:

   1. (1) Details of each such conviction, and whether the applicant is in compliance with any outstanding court orders entered for each such conviction, including copies of all relevant court documents;
   2. (2) If the applicant is currently under the care of a health professional who has recommended treatment a statement indicating whether or not the applicant is following the recommendations of the treating professional; and
   3. (3) If the applicant has been or is currently the subject of a civil suit involving the practice of the profession or their health care profession a copy of the settlement or judgment entered in such suit;

3. (c) A current resume or curriculum vita containing a chronologically organized account of the applicant's paid or volunteer work experience as a psychologist for the past 10 years or since the completion of the academic program, including:

   1. (1) Each separate experience in paid or volunteer work; and
   2. (2) The period of each separate experience described by the month and year it began and month and year it ended;

4. (d) Unless the information is available electronically, an official letter of verification sent directly to the OPLC from every jurisdiction which has issued a license or other authorization to practice and shall include at least one current license from a United States or Canada psychology licensing board, stating whether:

   1. (1) The license or other authorization is or was, during its period of validity, in good standing, and
   2. (2) Whether any disciplinary action was taken against the license or other authorization to practice; and
5. (e) A criminal history records check form and fingerprint card, seeking both a New Hampshire and a federal records check, in accordance with the procedure specified by the NH department of safety at Saf-C 5700 with the required fee in a separate check made payable to “State of NH: Criminal Records”.

Source. #13862, eff 4-2-24