1. (a) The application form shall:

   1. (1) Be provided by the board; and
   2. (2) Be kept confidential by the board pursuant to RSA 91-A:5.

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 the form the applicant shall designate the license sought in the space provided.

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

   1. (1) The date the applicant submits the form;
   2. (2) The applicant’s full legal 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 date of birth;
   5. (5) Using the “yes” and “no” boxes provided, an indication whether the applicant has already taken the licensing examination required for licensure;

   6. (6) Indicate by using the “yes” and “no” boxes provided:

      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 license or other authorization to practice as a fuel gas fitter or plumber in any jurisdiction;
      3. c. Whether the applicant has ever been the subject of any disciplinary action by any authority regulating fuel gas fitters or plumbers;
      4. d. Whether the applicant has had his or her license or other authorization to practice as a fuel gas fitter or plumber 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 fuel gas fitter or plumber 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 fuel gas fitters or plumbers; and
      7. g. Whether any claim on the basis of the applicant’s fuel gas fitting or plumbing work is pending against the applicant in any court; and

   7. (7) 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;

5. (e) On the application form the applicant shall place the date and his or her signature in the space provided above the following preprinted statement:

   "I acknowledge that, under RSA 641:3, 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 153:27 through RSA 153:38 and the rules of the Board and promise that, if I am licensed or certified, I will abide by them."

6. (f) On the application form the applicant shall provide the applicant’s:

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

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

      "The Mechanical Licensing 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 Mechanical Licensing Board and will be held confidential."

Source. #10648, EMERGENCY RULE, eff 7-25-14, EXPIRES: 1-21-15; ss by #10761, INTERIM, eff 1-21-15, EXPIRES: 7-20-15; ss by #10847, eff 7-1-15