Division of Public Health and Community Services 18 Mulberry Street - Nashua, NH 03060
(603) 589-4555 Fax (603) 594-3643 Welfare Department
This form must be completed by the agent in its entirety or it will not be accepted as valid.
THE PURPOSE OF THIS FORM IS FOR VERIFICATION OF INFORMATION OF GUESTS REGISTERED OR SEEKING TO STAY AT THE MOTEL ESTABLISHMENT.
The motel guest is responsible to return this completed form to the Welfare Department. The motel guest is responsible for complying with all rules and regulations of the motel establishment.