Section Alc 313.02 - Application Form On the board-provided "Application for Initial Licensure for Alcohol and Drug Counselor or Master Alcohol and Drug Counselor" form the applicant shall provide the following information:
(a) Whether the applicant is applying for initial licensure as a licensed alcohol and drug counselor or master licensed alcohol and drug counselor;(b) The applicant's full legal name;(c) Any other names ever used by the applicant;(d) The applicant's date of birth;(e) The applicant's current employer;(f) The applicant's current employer's mailing address;(g) The applicant's business e-mail address;(h) The applicant's business phone number;(i) Using the "yes" and "no" spaces provided, whether or not the applicant: (1) Has any pending criminal charges and, if so, an explanation of such charges;(2) Has made a plea agreement relative to any criminal charges and, if so, an explanation of such plea agreement;(3) Has a license or certification under revocation, suspension or probation in another state or territory of the United States;(4) Has practiced fraud or deceit in procuring or attempting to obtain this license;(5) Has engaged in sexual relations with, solicited sexual relations with, or committed an act of sexual abuse against or sexual misconduct with, a current or past client;(6) Has failed to remain free from the use of any controlled substance or any alcoholic beverage to the extent that its use impaired the applicant's ability to engage in work with individuals with substance and integrated co-occurring disorders;(7) Has engaged in false or misleading advertising;(8) Has any disciplinary action pending in another state or territory of the United States; and(9) Has a mental disability that impairs his or her professional ability or judgment;(j) If the applicant has answered any of the questions in Alc 313.02(i) above in the affirmative provide a detailed written explanation of the circumstances surrounding the "yes" answer and include any restitution(s) or remedial action(s);(k) Whether the applicant is currently or has been previously authorized by another jurisdiction to counsel individuals with substance use and integrated co-occurring disorders and, if "yes", by what jurisdiction(s);(l) The applicant's academic degree and degree granting institution;(m) List of the providers of the applicant's required drug and alcohol use education, supervised practical training, and clinical supervision;(n) List of the sites of applicant's required supervised work experience;(o) The applicant's physical home address;(p) The applicant's home mailing address;(q) The applicant's home phone number or cell phone number;(r) The applicant's personal email address;(s) Pursuant to RSA 161-B:11 and RSA 330-C:20, I, the applicant's social security number for the purpose of child support enforcement compliance with RSA 161-B:11;(t) The applicant shall sign and date the "Initial Application for Licensure as an Alcohol and Drug Counselor or Master Alcohol and Drug Counselor" below the following pre-printed statement: "The information provided on this application form and in the materials, I have provided to support my application is true, accurate, and complete to the best of my knowledge and belief. I acknowledge that, pursuant to RSA 641:3, the knowing making of a false statement on this application form is punishable as a misdemeanor". I have read and understand the laws, rule, and ethical standards for an Alcohol and Drug Counselor or for a Master Alcohol and Drug Counselor and if I am licensed I will abide by those laws, rules and ethical standards."
N.H. Admin. Code § Alc 313.02
Derived From Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12001, Effective 10/13/2016, Expires 10/13/2026.Amended by Number 6, Filed February 9, 2023, Proposed by #13518, Effective 3/13/2023, Expires 3/13/2033 (see Revision Note at chapter heading for Alc 300).