1. (a) Applicants for a designated caregiver registry identification card shall submit a completed “Caregiver 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;

   3. (3) The following information for each qualifying patient the applicant will be assisting with the therapeutic use of cannabis, which shall not exceed 5 qualifying patients, except that additional qualifying patients shall be allowed, up to a maximum of 9, if both the designated caregiver and the additional qualifying patients each live greater than 50 miles from the nearest ATC:

      1. a. Full name;
      2. b. Mailing address;
      3. c. Physical address, if different than mailing address, except that if the qualifying patient is experiencing homelessness this shall not be required; and
      4. d. Date of birth;

   4. (4) 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 patient’s medical 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 Qualifying Patient(s), more than 2 ounces of cannabis per Qualifying Patient, or obtain more than 2 ounces of cannabis in any 10-day period from any source per Qualifying Patient.”;
      4. d. “I understand that as a Designated Caregiver I am not permitted to use cannabis, unless I am also a Qualifying Patient, and may be subject to criminal penalties if I do so.”;
      5. e. “I understand that as a Designated Caregiver I am not permitted to possess any cannabis for purposes other than its therapeutic use as permitted by RSA 126-X.”;
      6. f. “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.”;
      7. g. “I understand that in the event of my Qualifying Patient’s death, I will, within 5 days of the death: (1) notify the Department of the death; and (2) either request that the local law enforcement agency remove any remaining cannabis or dispose of the remaining cannabis in a manner that is specified in RSA 126-X:2, XIV.”;
      8. h. “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.”;

      9. i. “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 this RSA 126-X.”;

         j “I understand that the protections granted by RSA 126-X for the therapeutic use of cannabis apply only within New Hampshire.”;

      10. k. “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
      11. l. “I understand that I, by possessing cannabis, and my Qualifying Patient, by using cannabis, 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.”;
   5. (5) A signed and dated attestation that the applicant has not been convicted of a felony offense in New Hampshire or in any other state, and agreement to notify the department if convicted of a felony offense subsequent to being issued a registry ID card;

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

      1. a. The applicant agrees to act as the designated caregiver for the qualifying patient named in the application;
      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;
   7. (7) 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

   8. (8) 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) The applicant shall submit the documents in (a) 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