1. (a) The certification renewal application form, “Training Program Application for Renewal of Certification”, provided by the board shall:

   1. (1) Be completed using a computer or legibly printed in ink; and
   2. (2) Have all sections completed or designated as not applicable.

2. (b) The form shall require the following information to be provided by the individual applying for renewal of certification to operate a training program, or the representative of the business entity applying for such certification:

   1. (1) Identification in the form of:

      1. a. The name of the individual or business entity;
      2. b. The business address, business telephone number, and website, if applicable, of the individual or business entity;
      3. c. The e-mail address for the individual or business entity, if there is one;
      4. d. If it is a business entity that seeks certification, the name of the representative, and the relationship of the representative making the application to the business entity seeking certification; and
      5. e. The business address, business telephone number, and website, if applicable, of such representative;
   2. (2) Additional information to assist the board in determining eligibility for certification;

   3. (3) The signature of the authorized signer below the following pre-printed statement:

      “I certify that the information provided on this application form for renewal of certification and the materials provided to support the application are, to the best of the signer’s knowledge and belief, true, accurate, complete and unaltered. The signer acknowledges that, pursuant to RSA 641:3, the knowing making of a false statement on the application form is punishable as a misdemeanor. The signer also acknowledges that the provision of false information in the application is a basis for disciplinary action by the Board.”; and

   4. (4) The date the signature is placed on the application form.

3. (c) The signature shall constitute:

   1. (1) A certification that the information provided on the application form for renewal of certification and the materials provided to support the application are, to the best of the signer's knowledge and belief, true, accurate, complete, and unaltered; and
   2. (2) The acknowledgement that, pursuant to RSA 641:3, knowingly making a false statement on the application form for renewal of certification is punishable as a misdemeanor.

Source. #9156, eff 5-10-08; ss by #9676, eff 4-2-10; ss by #12507, INTERIM, eff 4-2-18, EXPIRED: 10-1-18 New. #12638, eff 10-2-18