21 NCAC 32B .1702 APPLICATION FOR LIMITED VOLUNTEER LICENSE
(a) The Limited Volunteer License is available to physicians who hold an active license in a state or jurisdiction other than North Carolina, and who wish to volunteer at civilian indigent clinics.
(b) In order to obtain a Limited Volunteer License, an applicant shall:
(1) submit a completed application, attesting under oath or affirmation that the information on the application is true and complete, and authorizing the release to the Board of all information pertaining to the application;
(2) submit a photograph, two inches by two inches, affixed to the oath or affirmation attested to by a notary public;
(3) submit documentation of a legal name change, if applicable;
(4) submit proof of active licensure from another state or jurisdiction indicating the status of the license and whether or not any action has been taken against the license;
(5) submit a certified copy of applicant's birth certificate if the applicant was born in the United States or a certified copy of a valid and unexpired US passport. If the applicant does not possess proof of U.S. citizenship, the applicant must provide information about applicant's immigration and work status which the Board will use to verify applicant's ability to work lawfully in the United States;
(6) submit a NPDB report, dated within 60 days of submission of the application;
(7) submit a FSMB Board Action Data Bank report;
(8) submit two completed fingerprint record cards supplied by the Board;
(9) submit a signed consent form allowing a search of local, state, and national files for any criminal record;
(10) pay to the Board a non-refundable fee pursuant to G.S. 90-13.1(a) to cover the cost of a criminal background check;
(11) upon request, supply any additional information the Board deems necessary to evaluate the applicant's competence and character.
(c) All materials must be submitted directly to the Board from the primary source, when possible.
(d) An applicant may be required to appear in person for an interview with the Board or its agent to evaluate the applicant's competence and character.
(e) An application must be completed within one year of the date of submission.
History Note: Authority G.S. 90-8.1; 90-12.1A;
Eff. August 1, 2010;
Amended Eff. November 1, 2013;
Pursuant to G.S. 150B-21.3A rule is necessary without substantive public interest Eff. March 1, 2016.