SECTION .0200 ‑ EXAMINATION AND LICENSING

21 NCAC 52 .0201 APPLICATION

(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.

(b) Applicants shall furnish the board with proof that the applicant meets the educational and examination requirements set forth in G.S. 90-202.5(a)

(d) Applications shall also be notarized by a Notary Public in good standing.

History Note: Authority G.S. 90‑202.5; 90‑202.6; 90‑202.7;

Eff. February 1, 1976;

Amended Eff. June 1, 2011; April 1, 2005; January 1, 2005; December 1, 1988;

Readopted Eff. September 1, 2016;

Amended Eff. May 1, 2017.