21 NCAC 32B .1704 APPLICATION FOR RETIRED LIMITED VOLUNTEER LICENSE
(a) The Retired Limited Volunteer License is available to physicians who have been licensed in North Carolina or another state or jurisdiction, have an inactive license, and who wish to volunteer at indigent clinics.
(b) An applicant who has never held a North Carolina license but held an active license in another state or jurisdiction, which is currently inactive, 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 which has been attested to by a notary public;
(3) submit documentation of a legal name change, if applicable;
(4) supply 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;
(5) submit proof of licensure from another state or jurisdiction indicating the status of the license and whether or not any action has been taken against the license;
(6) submit two completed fingerprint record cards supplied by the Board;
(7) submit a signed consent form allowing a search of local, state and national files for any criminal record;
(8) 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;
(9) submit a FSMB Board Action Data Bank report;
(10) submit a NPDB report, dated within 60 days of submission of the application;
(12) upon request, supply any additional information the Board deems necessary to evaluate the applicant's competence and character.
(13) All materials must be submitted to the Board from the primary source, when possible.
(c) An applicant who holds an active North Carolina physician license may convert that to a Retired Limited Volunteer License by completing the Application for Retired Volunteer License.
(d) An applicant who held a North Carolina license which has been inactive less than six months may convert to a Retired Limited Volunteer License by completing the Application for Retired Volunteer License.
(e) An applicant who held a North Carolina license which has been inactive for more than six months but less than two years shall meet the requirements set forth in 21 NCAC 32B .1360.
(f) An applicant who held a North Carolina license which has been inactive for more than two years shall meet the requirements set forth at 21 NCAC 32B .1350.
(g) A physician who has been out of practice for more than two years will be required to complete a reentry program as set forth in 21 NCAC 32B .1370.
(h) 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.
(i) 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.