An applicant for initial licensure as a LADC or a MLADC shall submit to the board, or arrange for the submission of, the following additional materials:

1. (a) The completed, signed, and notarized form required by the New Hampshire division of state police for the issuance and transmission to the board of the applicant's state and federal criminal conviction record reports;
2. (b) A criminal history records check form and fingerprint card or live scan document, requesting both a New Hampshire and a federal records check, in accordance with the procedure specified by the NH department of safety at Saf-C 5700, Operation of the Central Repository: Criminal Records, with the required fee. The fee for the criminal history records check shall be submitted using a separate payment.

3. (c) Unless the information is available only on a secure website, an official verification letter sent directly to the board by every jurisdiction which has issued a license, certificate, or other authorization to practice counseling of individuals with substance use and integrated co-occurring disorders stating:

   1. (1) Whether the license, certificate, or other authorization is or was, during its period of validity, in good standing, and
   2. (2) Whether any disciplinary action was taken against the license, certificate, or other authorization to practice;
4. (d) A written description of the circumstances if the applicant has indicated “yes” to any of the “yes-no” questions on the “Application for Initial Licensure as an Alcohol and Drug Counselor or Master Alcohol and Drug Counselor” form or has been convicted of a felony;

5. (e) An official transcript:

   1. (1) Sent directly to the board's office by the degree-granting educational institution; and
   2. (2) Showing, for the LADC applicant, the award of one of the academic degrees required by Alc 307.03(b) and, for the MLADC applicant, the award of the master's degree required by Alc 310.02;
6. (f) Proof directly from the IC&RC that they have received a passing score on the IC&RC examination;

7. (g) For the purpose of documenting receipt of the required hours of drug and alcohol use education, as many of any of the following 3 kinds of documents as needed to document all of the applicant's hours:

   1. (1) An official academic transcript showing the hours of drug and alcohol use education included in the academic program;

   2. (2) One or more certificates signed by a representative of a program listed in Alc 307.03(c)(2)b. and Alc 310.03(b)(3):

      1. a. Showing the receipt by the applicant of drug and alcohol use education; and

      2. b. Including the following:

         1. 1. Whether the program is pre-approved and, if so, by whom;
         2. 2. The name of the applicant;
         3. 3. The number of hours of drug and alcohol use education received by the applicant;
         4. 4. The title of the drug and alcohol use education;
         5. 5. The category or categories of competence covered;
         6. 6. The name and location of the program;
         7. 7. The name of the program director or programs representative;
         8. 8. The signature of the program representative;
         9. 9. The date of the signature; and
         10. 10. If the program is not pre-approved, a description or outline of the training which contains the information described in 2. – 9. above including a syllabus or brochure of for the program and a description of the category or categories of competence covered by the training;
8. (h) For the purpose of documenting receipt of the required hours of supervised practical training in alcohol and drug counseling, as many completed board-provided “Supervised Practical Training Report Form” further described in Alc 313.05 as are necessary to document all of the applicant's hours;

9. (i) For the purpose of documenting the applicant's accumulation of the supervised experience required by Alc 307.05 or Alc 310.05, as applicable, the following forms:

   1. (1) A single board-provided applicant “Supervised Work Experience Report Form” further described in Alc 313.06; and
   2. (2) As many board-provided “Supervised Work Experience Report Form”, further described in Alc 313.06, as necessary for the supervisor(s) at each individual agency, program, or other entity separately to report the applicant's work experience supervised by such supervisor(s) at his, her, or their own site(s);
10. (j) For each employer listed in the applicant’s “Supervised Work Experience Report Form” described in Alc 313.06, an “Verification of Employment Form”, further described in Alc 313.08;
11. (k) A “Supervision Agreement”, further described in Alc 313.09;
12. (l) A “Applicant Evaluation Form”, further described in Alc 313.10; and
13. (m) An “Education and Training Summary Form”, further described in Alc 313.11.

Source. #12001, eff 10-13-16; ss by #13518, eff 3-13-23 (see Revision Note for chapter heading for Alc 300)