1. (a) Applicants for a qualifying patient registry identification card shall submit a completed “Patient Application” form to the department, which includes the following:

   1. (1) Indication whether it is an initial or renewal application;

   2. (2) The following applicant information:

      1. a. Full name;
      2. b. Date of birth;
      3. c. Gender;
      4. d. Telephone number;
      5. e. Mailing address; and
      6. f. Physical address, if different than mailing address, except that if the applicant is experiencing homelessness this shall not be required;

   3. (3) The following information about the applicant’s certifying provider:

      1. a. First and last name;
      2. b. Business address; and
      3. c. Telephone number;
   4. (4) A signed and dated release authorizing the release of relevant medical information by the certifying provider to the department if further information about the applicant’s qualifying medical condition or written certification is required by the department;

   5. (5) The following information about the applicant’s designated caregiver, if the applicant has designated a caregiver:

      1. a. Full name;
      2. b. Mailing address;
      3. c. Date of birth; and
      4. d. Indication that a “Caregiver Application” is enclosed or has already been submitted;

   6. (6) A signed and dated attestation of the following acknowledgements:

      1. a. “I understand that my Registry ID Card is valid for one year, unless a shorter or longer duration is indicated by my provider. I must renew or extend my card prior to its expiration in order to prevent a lapse in registration.”;
      2. b. “I understand that if I am notified of a denial or a revocation I have 30 days from the date of the notice to appeal the decision, and that if an appeal request is not made within that timeframe then I will have waived my right to an appeal and the action of the Department shall become final.”;
      3. c. “I understand that I may not possess, between myself and my Designated Caregiver, more than 2 ounces of cannabis, or obtain more than 2 ounces of cannabis in any 10-day period from any source.”;
      4. d. “I understand that I may only use cannabis for the purpose of treating or alleviating my qualifying medical condition.”;
      5. e. “I understand that I may not be under the influence of cannabis: (1) while operating a motor vehicle, commercial vehicle, boat, vessel, or any other vehicle propelled or drawn by power other than muscular power; (2) in my place of employment, without the written permission of my employer; or (3) while operating heavy machinery or handling a dangerous instrumentality.”;
      6. f. “I understand that I may not smoke or vaporize cannabis in any public place, including a public bus or other public vehicle, or any public park, public beach, or public field.”;
      7. g. “I understand that I may not be in possession of cannabis in any of the following locations: (1) the building and grounds of any preschool, elementary, or secondary school, which are located in an area designated as a drug free zone; (2) a place of employment, without the written permission of the employer; (3) any correctional facility; (4) any public recreation center or youth center; or (5) any law enforcement facility.”;
      8. h. “I understand that I may use cannabis on privately-owned real property only with written permission of the property owner or, in the case of leased property, with the permission of the tenant in possession of the property.”;
      9. i. “I have instructed a family member, caretaker, executor, and my Designated Caregiver that, in the event of my death, the Department shall be notified within 5 days that I have died, and that within 5 days of learning of my death, the family member, caretaker, executor, or my Designated Caregiver shall either request that the local law enforcement agency remove any remaining cannabis or dispose of the cannabis in a manner that is specified in RSA 126-X:2, XIV.”;
      10. j. “I understand that if I am found to be in possession of cannabis outside of my home and I am not in possession of my Registry ID Card, I may be subject to a fine of up to $100.”;
      11. k. “I understand that any person(s) who makes a fraudulent representation to a law enforcement official of any fact or circumstance relating to the therapeutic use of cannabis to avoid arrest or prosecution shall be guilty of a violation and may be fined $500, which shall be in addition to any other penalties that may apply for making a false statement to a law enforcement official or for the use of cannabis other than use undertaken pursuant to RSA 126-X.”;
      12. l. “I understand that the protections granted by RSA 126-X for the therapeutic use of cannabis apply only within New Hampshire.”;
      13. m. “I understand that I must be in compliance with RSA 126-X and with the administrative rules adopted thereunder, and that the Department may revoke my Registry ID Card for any violation of any provision of RSA 126-X or the rules adopted thereunder.”; and
      14. n. “I understand that by using cannabis I may be denied rights and privileges by federal agencies including, but not limited to, those related to employment such as driving a commercial vehicle, those related to owning, possessing, or purchasing a firearm and ammunition, those related to federally subsidized housing, those related to immigration and naturalization, or the inability to pass a security clearance.”;

   7. (7) A signed and dated certification that:

      1. a. The applicant is a resident of New Hampshire;
      2. b. The facts as stated in the application are accurate to the best of the applicant’s knowledge and belief; and
      3. c. The applicant understands that any false statements made on the application are punishable as unsworn falsification under RSA 641:3;
   8. (8) A signed and dated pledge not to divert cannabis to anyone who is not allowed to possess cannabis pursuant to RSA 126-X, acknowledgement that diversion of cannabis shall result in revocation of their registry identification card, and acknowledgement that the sale of cannabis to anyone who is not a qualifying patient or a designated caregiver is punishable as a class B felony with a sentence of a maximum term of imprisonment of not more than 7 years, and a fine of not more than $300,000, or both, in addition to other penalties for the illegal sale of cannabis; and

   9. (9) Voluntary demographic information, as follows:

      1. a. Race and ethnicity;
      2. b. Veteran status;
      3. c. Employment and income;
      4. d. Public assistance;
      5. e. Education;
      6. f. Health insurance;
      7. g. Marital status; and
      8. h. Language proficiency.

2. (b) In addition to (a) above, applicants shall provide to the department the following supporting documentation:

   1. (1) A “Written Certification for the Therapeutic Use of Cannabis” form completed by the applicant’s provider in accordance with He-C 401.07, except that a written certification completed more than 6 months prior to the date of the applicant’s application submission shall not be accepted;
   2. (2) A fee in accordance with He-C 401.14(b)(1); and

   3. (3) Proof of New Hampshire residency, as follows:

      1. a. A copy of the applicant’s valid, non-expired New Hampshire driver’s license or New Hampshire state identification;
      2. b. A copy of the applicant’s valid, non-expired state or federal government-issued identification that shows the applicant’s name and New Hampshire address; or

      3. c. If documentation in a. and b. above is unavailable, other documentation that contains the applicant’s name and current address and which indicates New Hampshire residency, such as:

         1. 1. A current lease agreement or vehicle registration; or
         2. 2. A utility bill, medical bill, property tax bill, mortgage statement, bank statement, government check, or payroll check with a date showing that it was issued within 6 months of the date the application was received by the department.

3. (c) The applicant shall submit the documents in (a) and (b) above to:

   NH Department of Health and Human Services

   Therapeutic Cannabis Program

   29 Hazen Drive

   Concord, NH 03301

Source. (See Revision Note #1 at part heading for He-C 401) #10646, eff 11-2-15; ss by #13220, eff 7-1-21 (see Revision Note #2 at part heading for He-C 401); ss by #13567, eff 5-1-23