Section Saf-Mec 304.02 - Application Form to be Used by Applicants for Individual Licenses(a) The "Initial Application for Licensure" form shall be provided by the board.(b) The applicant shall: (1) Complete the entire form using a keyboard or by printing the information legibly in ink;(2) Complete all sections of the entire form or designate them as not applicable; and(3) Sign and date the form.(c) On the form, provided by the board, the applicant shall provide the following information: (1) Designate the license sought;(2) The applicant's full legal name; (3) If applicable, the applicant's maiden name or any other name used by the applicant which is different from the applicant's current name;(4) Home physical address;(5) Home mailing address;(6) Home telephone or cell phone number;(7) Home e-mail address; and(8) The applicant's date of birth;(9) The applicant's social security number written immediately above the following preprinted statement: "Per RSA 161-B:11; The Mechanical Licensing Board is required to obtain your social security number for the purpose of child support enforcement. Except for its use in child support enforcement, your social security number will not be used by the Mechanical Licensing Board and will be held confidential."
(10) Answer yes or no to the following questions: a. "After the age of majority have you been convicted of a felony or, any criminal offense involving injury to a victim or the risk of such injury or any criminal offense involving dishonesty?"b. "Have you ever been denied, subject to disciplinary action, had your license or authorization to practice suspended or revoked or not reinstated in any state or jurisdiction?";c. "Have you ever been the subject of any disciplinary action by any professional regulating authority?";d. "Have you ever surrendered or relinquished your license or authorization to practice in any state or jurisdiction in order to avoid or to settle disciplinary charges?";f. "Do you have any reason to believe you will soon be the subject of a disciplinary proceeding, settlement agreement or consent decree undertaken or issued by any licensing or regulating authority in any jurisdiction?"; andg. "Is their any claim on the basis of your professional work pending against you in any court?";h. "Has applicant already taken the licensing examination required for licensure?"; and(11) The business name, full physical and mailing address, and telephone number of: a. The applicant's own business, if any; orb. The applicant's employer, if any.(d) The applicant shall place the date and their signature in the space provided above the following preprinted statement: "I acknowledge that, under RSA 641:3, I, knowingly making a false statement on this application form is a misdemeanor. I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read RSA 153:27 through RSA 153:38 and the rules of the Board and promise that, if I am licensed or certified, I will abide by them."
N.H. Admin. Code § Saf-Mec 304.02
Derived From Volume XXXV Number 27, Filed July 9, 2015, Proposed by #10847, Effective 7/1/2015, Expires 7/1/2025.Amended by Number 45, Filed November 9, 2023, Proposed by #13770, Effective 12/10/2023, Expires 10/12/2033 (formerly Saf-Mec 304.02) (see Revision Note at chapter heading for Mec 300).