1. (a) The application form shall be the “Application for Voluntary Certification of Heating Technicians and Heating Equipment Service Personnel” requiring the following information be provided:

   1. (1) Whether the application is for an initial or renewal certification;
   2. (2) If the application is for a renewal of certification the previous certification number;
   3. (3) The applicant’s full legal name;
   4. (4) Social security number pursuant to RSA 161-B:11;
   5. (5) The applicant’s home mailing address;
   6. (6) The applicant’s home or cell phone number;
   7. (7) The applicant’s date of birth;
   8. (8) The applicant’s current employer;
   9. (9) The applicant’s current employers mailing address;
   10. (10) The current employer’s phone number;
   11. (11) The current employer’s e-mail address; and

   12. (12) The applicant’s signature, printed full name, and the date of signing below the following preprinted statement:

       "I acknowledge that knowingly making a false statement on this application form is a misdemeanor under RSA 641:3 I certify that the information I have provided on all parts of the application form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read the statute and the rules of the Board and promise that, if I am licensed, I will abide by them."

2. (b) The applicant for voluntary certification affidavit form shall be the “Affidavit for Proof of Appropriate Field Experience” requiring the following information be provided:

   1. (1) The applicant’s legal name;

   2. (2) The following information related to each field experience:

      1. a. Start and end date;
      2. b. Name of company where the field experience was obtained including the company’s phone number;
      3. c. The supervisor’s printed name; and
      4. d. The type of work performed;
   3. (3) Any additional comments or information the applicant wishes the board to consider related to the field experience; and

   4. (4) The applicant’s signature and the date of signing below the following preprinted statement:

      "I acknowledge that, under RSA 641:3, I knowingly making a false statement on this affidavit form is a misdemeanor. I certify that the information I have provided on all parts of the affidavit form and in the documents that I have personally submitted to support my application is complete and accurate to the best of my knowledge and belief. I also certify that I have read RSA 153:27 through RSA 153:38 and the statues and rules of the board and promise that, if I am licensed or certified, I will abide by them."

   5. (b) The effect of the applicant’s signature on the forms described in (a) and (b) above shall be certification that the information supplied on the forms and in any additional information provided with the form(s) are true and correct to the best of the applicant’s knowledge and belief and is subject to the penalty for making false statement under RSA 641:3.

Source. #13631, eff 7-9-23