1. (1) the name and business address of each stockholder owning more than 10 percent of the issued and outstanding stock of a corporation;
2. (2) the name of the dispenser who is the manager or supervisor at each permanent business location;
3. (3) the principal office of the business entity, whether or not the dispensing of hearing aids is conducted at such principal office;
4. (4) whether the applicant, any partner or officer thereof has had a license or registration denied, suspended or revoked in any jurisdiction. If so, the details thereof shall be supplied;
5. (5) whether any administrative charges or complaints have been brought against the applicant, any partner or officer thereof in any jurisdiction. If so, details thereof shall be supplied;
6. (6) whether the applicant, any partner or officer thereof has been convicted of a crime or offense other than a minor traffic violation in any jurisdiction. If so, a certified copy of the conviction shall be attached to the application; and

7. (7) whether the applicant, any partner or officer thereof has ever been engaged in the business of fitting, renting or selling hearing aids in any jurisdiction. If so, the name under which and the address at which such business was conducted shall be supplied.

   (b) Assumed name.

   If the application is submitted by an individual or unincorporated association using an assumed name or by a partnership, the application shall include a certified copy of the certificate of doing business under the assumed or partnership name filed with the county clerk. If the application is submitted by a corporation, limited partnership or limited liability company using an assumed name, the application shall include a copy of the certificate of assumed name filed with the department.

   (c) Signing of application.

   The application shall be signed and affirmed by the applicant under penalty of perjury. An application made on behalf of a partnership or corporation shall be executed by the managing general partner or corporate officer who shall have been named in the application as the principal partner or officer.

   (d) Restriction as to name.

   A name may not contain any word or words which may imply that the applicant provides any medical treatment or audiometric examinations.

8. (e) A not-for-profit corporation, agency, association or entity which dispenses hearing aids shall register and comply with the provisions of this Part, where applicable.

(a) Contents of application.

In addition to the information listed in General Business Law, section 790, the application shall set forth: