The materials supporting the reinstatement application shall be as described below:

1. (a) A recent passport size, 2" x 2", original head shot photograph;
2. (b) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to the "yes-no" questions on the confidential part of the application form is in the affirmative;
3. (c) On a separate sheet, a detailed report of the relevant circumstances if any of the answers to the "yes-no" questions on the non-confidential part of the application form is in the affirmative;
4. (d) On a separate sheet, a statement that the reinstatement applicant has not practiced speech-language pathology in New Hampshire since the date the license lapsed;
5. (e) A photocopy of both sides of a currently valid certificate of clinical competence;

6. (f) A resume including a chronologically organized account of all the applicant's paid or volunteer activities in another jurisdiction since the date the New Hampshire license lapsed:

   1. (1) Delivering speech-language pathology services directly to clients;
   2. (2) As an educator in speech-language;
   3. (3) As an administrator in speech-language, speech-language pathology, occupational therapy, physical therapy, rehabilitation services, or special education;
   4. (4) Contributing expertise in speech-language to a speech-language pathology board or committee; and
   5. (5) As a speech-language pathology consultant;

7. (g) Unless the information is available only on a website, an official letter of verification sent directly to the board from every jurisdiction which has issued a license or other authorization to practice speech language pathology since the date that the license lapsed:

   1. (1) Stating that such license or other authorization is or was, during its period of validity, in good standing; and
   2. (2) Stating whether any disciplinary action was taken against the license or other authorization to practice;

8. (h) An original, not a photocopy, of a criminal offender record report:

   1. (1) Issued by each state where the applicant has resided and/or been licensed within the past 6 years, providing that such state has sent the report:

      1. a. To the board and the board has received the report; or
      2. b. To the applicant for forwarding to the board, and the board has received the report;
   2. (2) Covering the applicant under his or her name and any aliases; and
   3. (3) Dated within the 6 months predating the application for licensure; and
9. (i) Any documentation required in Spe 303.04 which was not previously provided to the Board.

Source. #9406, eff 3-7-09; ss by 9883-B, eff 3-5-11 (from Spe 403.06); ss by #10327, eff 5-4-13; ss by #10683, eff 10-4-14; ss by #10907, eff 8-7-15; ss by #11178, eff 9-17-16