North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 52 - PODIATRY EXAMINERS › Section .0200 - EXAMINATION AND LICENSING › Section 52 .0201 - APPLICATION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Any applicant
				for a license to practice podiatry shall submit a written application to the
				executive secretary of the board. Such Application for Examination or
				Application of Reciprocity shall be made on a form provided from the board's
				website (http://www.ncbpe.org)or from the board's office as set forth in Rule
				.0101 of this Chapter. The application shall require the following information:
(1) Application type (Regular, Temporary
				Military, Clinical Residency);
(2)
				Date of Application;
(3) Social
				Security Number;
(4) Drug
				Enforcement Administration License Number (DEA), if any;
(5) National Provider Number (NPI), if
				any;
(6) Last name, first name, and
				middle name;
(7) Mailing address,
				including city, state, and zip code;
(8) Telephone number and type (home, mobile,
				business);
(9) Email
				address;
(10) Whether or not a U.S.
				citizen;
(11) Whether or not the
				applicant has or is serving in the military, awarded an MOS in podiatry and
				date, whether or not the applicant's spouse is currently serving in the
				military, and dates of service;
(12) Education (high school, college or
				university, graduate or professional, residencies, internships, fellowship
				training), including name and location of institution, dates attended,
				graduation completion, major and minor, and type of degree received;
(13) Whether or not the applicant intends to
				practice in North Carolina upon licensure;
(14) Whether or not the applicant has been
				licensed in another state or territory and, if so, state or territory, date of
				issue, expiration date, disciplinary actions (if any), and how license was
				obtained;
(15) Whether or not the
				licensee has ever had a license revoked, suspended, denied, or cancelled;
				denied the privilege of taking an exam; dropped, suspended, warned, placed on
				scholastic or disciplinary probation, expelled, or requested to resign from any
				school, college, or university, or advised by any such school of institution to
				discontinue studies therein; been a defendant in a legal action involving
				professional liability (malpractice), been named in a malpractice suit, had a
				professional liability claim paid on the applicant's behalf or paid such a
				claim; been a patient for the treatment of mental illness; been addicted to
				drugs or alcohol; or been convicted of a felony; and any explanation regarding
				such information that the applicant wishes to present to the board.
(16) Whether or not the applicant has
				previously taken the North Carolina exam and when;
(17) Whether or not the applicant requires
				special disability accommodations to take the board's examination;
(18) The reasons why the applicant is
				applying for licensure in North Carolina;
(19) A list of three references;
(20) Applicant's oath;
(21) A passport-quality photograph taken
				within 60 days prior to the date of the application; and
(22) Applicant's signature.