Section Saf-Mec 804.02 - Application Form(a) The application form shall be the "Application for Voluntary Certification of Water Treatment Technician or Trainee" requiring the following information be provided: (1) Whether the application is for an initial or renewal certification;(2) If the application is for a renewal of certification the previous certification number;(3) The applicants full legal name;(4) Social security number required pursuant to RSA 161-B:11;(5) The applicant's home mailing address;(6) The applicant's home or cell phone number;(7) The applicant's date of birth;(9) The applicant's current employer;(10) The applicant's current employers mailing address;(11) The current employer's phone number;(12) The current employer's e-mail address; and(13) The applicant's signature, printed full name, and the date of signing below the following preprinted statement: "I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:3. 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 the statute and the rules of the Board and promise that, if I am licensed, I will abide by them."
(b) The effect of the applicant's signature on the form described in (a) above shall be certification that the information supplied on the form and attached to the form is true and correct to the best of the applicant's knowledge and belief, subject to the penalty for making false statement under RSA 641:3.N.H. Admin. Code § Saf-Mec 804.02
Derived from Number 23, Filed June 8, 2023, Proposed by #13632, Effective 7/19/2023, Expires 7/19/2033.