N.H. Code Admin. R. Ph 601.06
(b) Applications for renewal of a license to operate as a limited retail drug distributor shall consist of prescribed fee as indicated in Ph 601.01(e) and the following appropriate application form:
(c) Medical gas supplier and methadone maintenance/detoxification renewal applicants shall submit the following additional information with their renewal applications:
(1) For medical gas suppliers:
(2) For methadone maintenance/detoxification facilities:
(d) Renewal applications shall include a dated signature and title under the following affirmations:
(1) For medical gas suppliers:
“I affirm that I am the person authorized to sign this application for licensure on behalf of the company/licensee and affirm that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and belief is a true, correct and complete application, and if the registration herein applied for is granted, I hereby agree to and do submit to the jurisdiction of the New Hampshire Board of Pharmacy and to the laws and rules of this State.”
(2) For clinics under contract with DHHS:
“I declare under penalties of unsworn falsification under RSA 641:3 that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and belief is a true, correct and complete application, and if the permit herein applied for is granted, I hereby agree to and do submit to the jurisdiction of the New Hampshire Board of Pharmacy and to the laws and rules of this State.”; and
(3) For methadone maintenance/detoxification facilities:
“I declare under penalties of unsworn falsification under RSA 641:3 that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and belief is a true, correct and complete application, and if the permit herein applied for is granted, I hereby agree to and do submit to the jurisdiction of the New Hampshire Board of Pharmacy and to the laws and rules of this State. To the best of my knowledge, myself nor any of the employees listed on this application, have been arrested, investigated for, charged with, convicted of, sentenced, entered a plea of non contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by the federal government.”
(e) The board shall renew a license pursuant to this section if the applicant:
Source. #8572, eff 2-23-06, EXPIRED: 2-23-14 New. #12335, eff 7-22-17; ss by #13117, eff 10-15-20