1. (a) The reinstatement application form shall:

   1. (1) Be completed on the “Reinstatement Application Form” dated June 24, 2015;
   2. (2) Be provided by the board and available on the boards web site, www.nh.gov/alliedhealth; and

   3. (2) Be signed and dated below the following preprinted statement which asserts:

      "I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:2, I. I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read the statute and the rules of the Board and promise that, if I am licensed, I will abide by them."

2. (b) The effect of the reinstatement applicant’s notarized signature on the application form shall be:

   1. (1) The applicant’s acknowledgement that knowingly making a false statement on the application form is a misdemeanor under RSA 641:2, I;

   2. (2) The applicant’s certification that:

      1. a. The information provided on all of the parts of the application form and in the documents personally submitted to support the application is complete and accurate to the best of the applicant’s knowledge and belief; and
      2. b. The applicant has read the statutes and administrative rules of the board; and
   3. (3) The applicant’s promise to abide by the statutes and administrative rules of the board.

Source. #9406, eff 3-7-09; ss by #9883-B, eff 3-5-11 (from Spe 403.05); ss by #10907, eff 8-7-15