1. (a) The multipart application form shall:

   1. (1) Be provided by the board; and

   2. (2) Contain 2 parts as follows:

      1. a. Part one, containing information available to the public; and
      2. b. Part 2, which is held confidential by the board.

2. (b) The applicant shall:

   1. (1) Complete the entire form using a keyboard or by printing the information legibly in ink;
   2. (2) Complete all sections of the entire form or designate them as not applicable; and
   3. (3) Sign and date the form.
3. (c) On part one of the form the applicant shall designate in the space provided the license sought.

4. (d) Also on part one of the form the applicant shall provide the following information:

   1. (1) The date the applicant submits the form;
   2. (2) The applicant’s full name;
   3. (3) If applicable, the applicant's maiden name or any other name used by the applicant which is different from the applicant's current name;
   4. (4) The applicant's place and date of birth;
   5. (5) Using the “yes” and “no” boxes provided, an indication whether the applicant has already taken the licensing examination required by Plu 304;

   6. (6) The name, full business address and telephone number of:

      1. a. The applicant’s own business, if any; or
      2. b. The applicant’s employer, if any;

   7. (7) If applying for an initial license as a journeyman plumber:

      1. a. The name and address of the apprenticeship program or the program’s sponsor; and
      2. b. The date of issuance of the apprenticeship completion certificate by the apprenticeship council;
   8. (8) If applying for an initial license as a master plumber and holding a New Hampshire license as a journeyman plumber, the number of the journeyman plumber license;

   9. (9) If applying for an initial license as a master plumber or a journeyman plumber and holding a currently valid out of state license as a master plumber or a journeyman plumber:

      1. a. Whether the applicant’s currently valid out-of-state license is a journeyman or master plumber license;
      2. b. The name of the jurisdiction issuing the license;
      3. c. The number of the license; and
      4. d. The expiration date of the license; and
   10. (10) If applying for an initial license as a journeyman plumber, the names, addresses and telephone numbers of the 3 individuals who will provide letters of reference meeting the requirements of Plu 302.05(i).

5. (e) Also on part one of the form the applicant shall indicate by using the “yes” and “no” boxes provided:

   1. (1) Whether the applicant was convicted after the age of majority of:

      1. a. A felony;
      2. b. Any criminal offense involving injury to a victim or the risk of such injury; or
      3. c. Any criminal offense involving dishonesty;
   2. (2) Whether the applicant has ever been denied a license or other authorization to practice as a plumber in any jurisdiction;
   3. (3) Whether the applicant has ever been the subject of any disciplinary action by any authority regulating plumbers;
   4. (4) Whether the applicant has had his or her license or other authorization to practice as a plumber suspended or revoked and not thereafter reinstated in any other jurisdiction; and
   5. (5) Whether the applicant has ever surrendered a license or other authorization to practice as a plumber in any jurisdiction in order to avoid or to settle disciplinary charges.

6. (f) Also on part one of the form the applicant shall place the date, his or her printed name and his or her signature in the space provided beneath the following preprinted statement:

   "I acknowledge that, under RSA 641:2, I, knowingly making a false statement on this application form is a misdemeanor. 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 RSA 329-A and the rules of the Board and promise that, if I am licensed or certified, I will abide by them."

7. (g) On part 2 of the form the applicant shall provide the applicant’s:

   1. (1) Full name;
   2. (2) Home address;
   3. (3) Home telephone number;
   4. (4) Home e-address, if the applicant wishes to provide it; and

   5. (5) The applicant's social security number written immediately below the following preprinted statement:

      "The Plumbing Board is required by RSA 161-B:11 to obtain your social security number for the purpose of child support enforcement. Except for its use in child support enforcement, your social security number will not be used by the Plumbing Board and will be held confidential."

8. (h) Also on part 2 of the form the applicant shall indicate using the “yes” and “no” boxes provided:

   1. (1) Whether the applicant knows that he or she is or will soon be the subject of a disciplinary proceeding, settlement agreement or consent decree undertaken or issued by any authority regulating plumbers; and
   2. (2) Whether any claim on the basis of the applicant’s plumbing work is pending against the applicant in any court.

Source. #5213, eff 8-28-91, EXPIRED: 8-28-97 New. #8542, eff 1-20-06; ss by #8981, eff 9-20-07