Section Alc 304.02 - Application Form The applicant shall furnish the following information on the application form provided by the board:
(a) The applicant's full legal name;(b) Any other names ever used by the applicant;(c) The applicant's date of birth;(d) The applicant's current employer;(e) The applicant's current employers address, business email, and phone number;(f) Using the "yes" and "no" spaces provided, whether or not the applicant: (1) Has any pending criminal charges;(2) Has made a plea agreement relative to any criminal charge;(3) Has been convicted of a felony or misdemeanor in this or any jurisdiction;(4) Has any license or certification under revocation, suspension, or probation in another state or territory of the United States; and(5) Is currently on probation or parole in New Hampshire or in any other state or territory of the United States;(6) Has engaged in work with individuals with substance use or integrated co-occurring disorders in a manner harmful or dangerous to them or the public;(7) Has practiced fraud or deceit in procuring or attempting to obtain this certification;(8) Has engaged in sexual relations with, solicited sexual relations with, or committed an act of sexual abuse against or sexual misconduct with, a current or past participant or minor;(9) Has failed to remain free from the use of any controlled substance or any alcoholic beverage to the extent that the use impairs the applicant's ability to engage in work with individuals with substance use and integrated co-occurring disorders with safety to the public;(10) Has engaged in false or misleading advertising;(11) Has disciplinary action(s) pending in another state or territory of the United States;(12) Has a mental disability which impairs professional ability or judgment; and(13) Is currently or has previously been authorized in another jurisdiction to provided recovery support work;(g) If the applicant has answered any of the questions in Alc 304.02(g) in the affirmative provide a detailed written explanation of the circumstances surrounding the "yes" answer and include any restitution(s) or remedial action(s);(h) List the private and public settings in which the applicant completed the paid or volunteer work experience required by Alc 303.02;(i) List the sources of the education required by Alc 303.03;(j) The applicant's physical home address;(k) The applicant's home telephone number or cellular phone number;(l) The applicant's home mailing address;(m) The applicant's personal email address;(n) Pursuant to RSA 161-B:11 and RSA 330-C:20, I, the applicant's social security number for the purpose of child support enforcement compliance with RSA 161-B:11; and(o) The applicant shall sign and date the "Initial Certification Application as a Recovery Support Worker" below the following statement: "The information provided on this application form and in the materials, I have provided to support my application is true, accurate, and complete to the best of my knowledge and belief. I acknowledge that, pursuant to RSA 641:3, the knowing making of a false statement on this application form is punishable as a misdemeanor. I have read and understand the laws, rule, and ethical standards for Recovery Support Workers and if I am certified I will abide by those laws, rules, and ethical standards as defined in Alc 500."
N.H. Admin. Code § Alc 304.02
#9421, INTERIM, eff 3-14-09, EXPIRES: 9-10-09
Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12001, Effective 10/13/2016, Expires 10/13/2026.Amended by Number 6, Filed February 9, 2023, Proposed by #13518, Effective 3/13/2023, Expires 3/13/2033 (see Revision Note at chapter heading for Alc 300).