STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
www.nh.gov/labor
Elevator Division: Phone: 603-271-2585 Fax: 603-271-2668
LICENSE APPLICATION FOR:
Required:
□Elevator Inspector □Accessibility Lift Mechanic
□Elevator Mechanic □Accessibility Lift Inspector
□Initial Application □Renewal □Reinstatement
Last Name First Name Middle Initial
Home Mailing Address Email Address
City State Zip Code Cell Phone Number Home Phone Number
Business Name (Company you work for) Federal ID Number
NH Inspector / Mechanic License Number License Expiration Date
Do you hold a license in another State? Yes___ No____ Which State? ________
Has your license ever been suspended, revoked, limited or denied in this or any other jurisdiction? If yes,
please explain.
The application must be accompanied by a list of all related elevator work experience per Lab
1303.05 or 1303.06 including total hours worked on elevators or accessibility lifts for each year
including a name and phone number of a contact person at each location worked who can verify the
experience listed.
Renewal Fee: $35.00 New Application Fee: $50.00 Reinstatement Fee: $50.00
Please make check payable to Treasurer, State of New Hampshire, Application fees are not
refundable.
____________________________________________________ _____/_____/______
Signature Date
Form ELCA 3-16-18
