Form Dssp415 - Therapeutic Cannabis Program - Rsa 126-X4,8 (Page 2 of 2) in pdf

Additional Instructions – DHHS Therapeutic Cannabis Program

If you are applying to be a Qualifying Patient you DO NOT need to undergo a

criminal history record check.

All Designated Caregivers and all Alternative Treatment Center (ATC) Agents must complete a state and

federal criminal history record check.

Designated Caregivers – A criminal history record check shall be required for an initial application for a

•

registry identification card, and if there has been a lapse in registration. Designated Caregivers are not

required to complete a criminal history record check when they apply to renew their registry identification

card (unless there has been a lapse in registration). Instead, they must fill out an “Attestation of No

Felony Conviction” form, available on the Therapeutic Cannabis Program’s website, listed below.

Alternative Treatment Center Agents – A criminal history record check shall be required prior to

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beginning to work at an ATC.

Fingerprints. There are two ways to complete fingerprints for an FBI background check. Please read and

follow the instructions for the method you are using.

Department of Safety Fingerprint Station:

The stations listed below all use LiveScan (digital) fingerprinting:

NH Department of Safety: 33 Hazen Drive (James H.

Troop E – Ossipee Area: 1863 White Mountain

Hayes Building), Concord

Highway, Tamworth

DMV Dover Point: 50 Boston Harbor Road, Dover

Troop C – Keene Area: 15 Ash Brook Court, Keene

DMV Manchester Commons: 377 South Willow

Troop F – Littleton Area: 549 Route 302, Twin

Street, Manchester

Mountain

1. Call the appointment desk at the Department of Safety at 603-223-3867.

2. Bring the following 3 items to your appointment:

A notarized Criminal History Record Information Authorization for Therapeutic Cannabis form for each

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person who has an appointment. The form must be notarized before you arrive for your appointment.

Official photo identification for each person, such as a driver’s license, state-issued photo ID, or passport.

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A check or money order made payable to State of NH–Criminal Records for $47.00 for each person

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being fingerprinted.

ALTERNATE

Local Police Station with LiveScan: Local police may charge an additional service fee and may delay approval.

Make an appointment with your local police station to be fingerprinted. Call the local police station directly.

DO NOT CALL the appointment desk number listed above.

2. Bring the notarized Criminal History Record Information Authorization for Therapeutic Cannabis form.

3. The local police station will submit only fingerprints to the State Police; they will not submit the required forms or the fee.

4. Once fingerprinted, submit (a) the notarized Criminal History Record Information Authorization for Therapeutic Cannabis

form indicated in #2 above, (b) a check in the amount of $47.00 made payable to State of NH–Criminal Records, and (c)

the Live Scan Site form provided to you by the police station, by mailing them to:

Department of Safety, Division of State Police

Criminal Records Unit

33 Hazen Drive

Concord NH 03305

ALL SECTIONS OF THE CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION FOR THERAPEUTIC

CANNABIS FORM MUST BE COMPLETED FULLY IN INK AND MUST BE LEGIBLE. Incomplete forms may result in being

turned away from your appointment, resulting in additional fingerprinting and costs. All signatures must be original. Photocopies of the

signed and notarized form will not be accepted. Forms must be notarized before you arrive for your appointment. Do not mail this form to

the Therapeutic Cannabis Program

KEEP COPIES OF ALL DOCUMENTATION FOR YOUR RECORDS

Please visit

for additional information.

Form Dssp415 - Therapeutic Cannabis Program - Rsa 126-X4,8 Page 2

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