1. (a) The application form shall contain questions:

   1. (1) Designed to allow the board to make eligibility determinations based on the answers to the questions; and

   2. (2) Including the following questions to be answered by checking: yes” and “no” boxes:

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

         1. 1. A felony;
         2. 2. Any criminal offense involving injury to a victim or the risk of such injury; or
         3. 3. Any criminal offense involving dishonesty;
      2. b. Whether the applicant has ever been denied a certification or other authorization to practice as a water treatment technician;
      3. c. Whether the applicant has ever been the subject of any disciplinary action by any authority regulating water treatment technicians;
      4. d. Whether the applicant has had his or her certification or other authorization to practice as a water treatment technician suspended or revoked and not thereafter reinstated in any other jurisdiction;
      5. e. Whether the applicant has ever surrendered a license or other authorization to practice as a treatment technician in any jurisdiction in order to avoid or to settle disciplinary charges;
      6. f. 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 water treatment technicians; and
      7. g. Whether any claim on the basis of the applicant’s work as a water treatment technician is pending against the applicant in any court.

2. (b) On the application 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."

Source. #8981, eff 9-20-07