Section Sep 301.02 - Application for Licensure(a) Each applicant for licensure shall provide, or cause to be provided, the following on the "Application for Licensure as a Septic System Evaluator" form supplied by the board:(1) The applicant's name, including any names previously used;(2) The applicant's written signature;(3) The applicant's residence and business addresses and telephone numbers;(4) The applicant's email address;(5) The applicant's date of birth and place of birth;(6) An indication as to whether the applicant has completed the classroom and field training of a board approved septic evaluator course and, if so: a. The date of the course;b. Where the course was taken; andc. Name of the course provider;(7) An indication as to whether the applicant has ever taken a granite state septic system evaluator course and, if so, the date the course was taken;(8) An indication as to whether the applicant currently holds a septic system designer permit and, if so: a. The permit number; andb. The total number of evaluations completed;(9) An indication as to whether the applicant is actively engaged in the business of septic system evaluations and, if so: a. The year the applicant began evaluating septic systems; andb. The total number of evaluations completed;(10) The applicant's dated signature below the following attestation: I have read the contents hereof and clearly understand that the correctness and truth of my statements certifying that I have completed 25 septic system evaluations as recorded in this application not only to the issuance of the certificate of licensure, as applied for, but also to the retention of said certificate, if issued;
(11) An indication as to whether the applicant has ever been licensed in any other state as a septic system evaluator;(12) The applicant's dates of employment, titles of positions, and name and present address of employer;(13) Character of employment including types of work performed and degree of responsibility;(14) The name and present address of someone familiar with each position held by the applicant, preferably a person to whom the applicant reported or with whom the applicant was associated;(15) The name, address, occupation, and business relationship to the applicant of 3 references that have personal knowledge of the applicant's experience and who will submit a completed reference form to the board for review which contains the following information:a. The name of the applicant;b. The full name of the reference,c. The address of the reference;d. The reference's present business or profession;e. An indication as to whether the reference is a certified or practicing septic system evaluator and, if so, the state and applicable certificate number;f. The length of time the reference has known the applicant;g. An explanation of any relationship to the applicant;h. An explanation of any business connection to the applicant;i. Identification of anything the reference knows about the applicant that would reflect adversely on the applicant's integrity or general good character;j. A brief estimate of the applicant as a septic system evaluator;k. An indication as to whether the reference would employ the applicant in a position of trust;l. The name and address of the applicant's firm, if he or she is connected to one;m. Whether the reference thinks the applicant is qualified to be placed in a responsible charge of supervision of work;n. The nature of the applicant's individual practice, if he or she practices individually;o. Whether the reference recommends the applicant for certification as a septic system evaluator;p. An estimation of how many years of experience the reference believes the applicant to have;q. Any other remarks concerning the applicant; andr. The reference's dated signature below an attestation that the reference knows the person referred to is making application for licensure to the State of New Hampshire as a septic system evaluator;(16) Highest grade attended including name of institution, years attended, graduation date;(17) A listing of every state in which the applicant holds or has ever held registration or certification, licensure as a septic system evaluator with corresponding number and date of initial registration, certification, or licensure;(18) Whether the applicant has ever been denied registration, certification, or licensure as a septic system evaluator or disciplined by this board or another septic system evaluator licensing board in any other state and if so, an explanation of the circumstances;(19) Whether the registration, certification, or licensure as a septic system evaluator was issued by examination;(20) Whether the applicant has ever been convicted of any felony, any misdemeanor, or a violation and if so, the name of the court, the details of the offense and the date of conviction and the sentence imposed;(21) The applicant's social security number required pursuant to RSA 161-B:11, VI-a;(22) The applicant's signed and dated supplementary experience record, including the signed and dated attachments, which lists in detail the applicant's projects or assignments in chronological order by identifying: a. The portion of the work the applicant personally did;b. The project job title;c. The name of the client; andd. The location of the portion of the project completed by the applicant;(23) The applicant's dated signature below the following pre-printed affidavit: I have read the contents hereof and clearly understand that the correctness and truth of my statements as recorded in this application are material, not only to the issuance of the certificate of licensure, as applied for, but also to the retention of said certificate, if issued; and
(24) The application fee as specified in Sep 301.03 and Sep 301.04.N.H. Admin. Code § Sep 301.02
#12392, INTERIM, eff 9-28-17, EXPIRED: 3-27-18
New. #12654, eff 10-31-18
Derived From Volume XXXVIII Number 45, November 8, 2018, Proposed by #12654, Effective 10/31/2018, Expires 10/31/2028.