The applicant shall furnish the following information on the “Initial Licensed Clinical Supervisor Application Form” provided by the board:

1. (a) The applicant’s full legal name;
2. (b) The applicant’s work address;
3. (c) The applicant’s work telephone number;
4. (d) The applicant’s current license type and license number;
5. (e) The month and year the applicant was originally granted a MLADC or LADC license; and
6. (f) The applicant’s physical home address;
7. (g) The applicant’s home telephone number or personal cell phone number;
8. (h) The applicant’s home e-mail address; and

9. (i) The applicant’s dated signature below the following statement preprinted on the “Initial Licensed Clinical Supervisor Application Form”:

   “I certify that at least 2 years (4,000 hours) of my work experience has been clinical supervisory experience in the substance use and integrated co-occurring disorders field and includes a minimum of 200 contact hours of face-to-face clinical supervision that I have provided to others I supervise. 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 Alc 500 and if I am licensed as a clinical supervisor, I promise to abide by them.”

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