By signing the provider license application, the applicant shall certify that:

1. (a) The information provided in the application is complete, truthful, and correct under penalties of unsworn falsification pursuant to RSA 641:3;
2. (b) He or she has not been convicted or found guilty of an offense pursuant to RSA 153-A:13, I;
3. (c) He or she complies with RSA 153-A and these rules;
4. (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;
5. (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
6. (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.

Source. (See Revision Note #1 and Revision Note #2 at Chapter heading for Saf-C 5900) #12790, effective 5-24-19; (see also Revision Note at part heading for Saf-C 5904)