Fillable Application Checklist of Requirements for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application Checklist of Requirements for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Architects
Interior Design Examination and Evaluation Committee
124 Halsey Street, 3rd Floor, P.O. Box 45001
Newark, New Jersey 07101
(973) 504-6385
Application Checklist of Requirements for
Interior Design Certication (N.J.S.A. 45:3-38)
This application is being sent in response to your request for information concerning interior design certication
in New Jersey. The items listed below must be submitted before your application will be considered complete
and before it will be reviewed for approval. Please use this checklist to be sure that you have complied with all
of the requirements.
Application – Complete the attached application, have it notarized and attach one passport size photograph
and mail the completed application to the address above for consideration by the Committee.
Application Fee – Enclose a check or money order in the amount of $125.00 payable to the New Jersey State
Board of Architects.
Transcripts – Transcripts must be mailed directly to the New Jersey State Board of Architects Interior Design
Examination and Evaluation Committee at the address above by the college or university at the applicant’s
request.
Course Description Form – If your program was not FIDER/CIDA accredited, you must submit the course
description form for the Committee’s review.
N.C.I.D.Q. Examination Verication – If applicable, you must have verication of successful completion of the
examination provided directly to the Committee from N.C.I.D.Q.
References – You MUST complete Section I on all three reference forms. The Personal Reference forms are to
be distributed to two individuals, whom you have known for at least five (5) years, and the
Professional Reference form is to be distributed to a design professional such as a
state-certified/licensed interior designer, architect or professional engineer, who has firsthand
experience of your work. No reference shall be a relative of yours. Please provide each reference with an
envelope that already has a stamp afxed and the address of the Committee on it so that the form may be
mailed directly to the Committee.
Please contact our ofce should you have any questions.
- 1 -
New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Architects
Interior Design Examination and Evaluation Committee
124 Halsey Street, 3rd Floor, P.O. Box 45001
Newark, New Jersey 07101
(973) 504-6385
Application to Become a
Certied Interior Designer Pursuant to N.J.S.A. 45:3-38
Date: _______________________________
A nonrefundable application ling fee of $125.00 in the form of a check or money order made out to the New Jersey State Board of
Architects must be submitted with this application. (Applicants should understand that if the fee is paid with a personal check, and the
check is returned by the bank due to insufcient funds, the next step in the licensure or certication process will be delayed until the fee
is paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: ________________________
Month Day Year
Mr.
1. Name
Mrs. _________________________________________________________________( _______________________ )
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ __________________________________
Telephone number (include area code) E-mail address
Business: ____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
Do not use staples to attach the
photo.
For ofce use only
Application number:
________________________
- 2 -
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records; and
b. the Probation Division or any other agency responsible for child support enforcement, upon request.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation?
Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
click to sign
signature
click to edit
6. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be disclosed.) Yes No
7. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
8. Do you currently hold, or have you ever held a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. _____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
10. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
11. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever been named as a defendant in any litigation related to the practice of interior design or other professional practice in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
15. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of interior design or other professional practice in New Jersey, any other state, the District of Columbia or in
any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 9 through 15, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 3 -
- 4 -
Examination
1. Have you successfully completed the National Council for Interior Design Qualications (N.C.I.D.Q.) examination?
Yes No
If “Yes,” please provide the N.C.I.D.Q. certicate number. _________________________________
If you have taken the examination prior to making application, then you must request that N.C.I.D.Q. provide verication of
successful completion of the examination.
Education
You must request that an ofcial transcript of your interior design education be mailed by the college or university directly to
the New Jersey State Board of Architects at the address on the rst page. In addition to the ofcial transcript, if the program is
NOT accredited by the Council for Interior Design Accreditation (CIDA), the applicant must provide on the enclosed blue form
a concise description for each of the interior design courses successfully completed.
1. Did you graduate from an interior design program? Yes No
a. If “Yes,” then check the appropriate box: 5-year program 4-year program 2-year program
b. If you did NOT graduate, then did you successfully complete at least three years in an interior design program which is
comprised of at least 90 semester credits (or their equivalent) of which at least 60 semester credits (or their equivalent) are
in interior design-related course work? Yes No
2. Was the interior design program accredited by FIDER/CIDA at the time of graduation? Yes No
List the names and addresses of the colleges or universities you have attended as well as the degree(s) obtained:
A. __________________________________________________________________________________________________
Name of college / university
__________________________________________________________________________________________________
Street address City State ZIP code
________________________ _________________________ _____________________ ________________
Inclusive Years Attended Degree or Certicate Major Date Granted
B. ___________________________________________________________________________________________________
Name of college / university
___________________________________________________________________________________________________
Street address City State ZIP code
________________________ _________________________ _____________________ ________________
Inclusive Years Attended Degree or Certicate Major Date Granted
C. ___________________________________________________________________________________________________
Name of college / university
___________________________________________________________________________________________________
Street address City State ZIP code
________________________ _________________________ _____________________ ________________
Inclusive Years Attended Degree or Certicate Major Date Granted
DOCUMENTATION OF DIVERSIFIED INTERIOR DESIGN SERVICES EXPERIENCE
Education and experience requirements:
• If you are a graduate from a ve-year interior design program, then you must demonstrate at least one year of diversied
interior design services experience;
• If you are a graduate from a four-year interior design program, then you must demonstrate at least two years of diversied
interior design services experience;
• If you are a graduate from a two-year interior design program, then you must demonstrate at least four years of diversied
interior design services experience;
• If you have successfully completed at least three years of an interior design curriculum (comprised of at least 90 semester
credits (or their equivalent) of which at least 60 semester credits (or their equivalent) are in interior design-related course
work), then you must demonstrate at least three years of diversied interior design services experience.
• The Committee shall only consider a candidate’s experience after the successful completion of 40 semester credits (or their
equivalent) in interior design-related course work.
- 5 -
Begin with your current or most recent employment and then provide the relevant information as you work back in time,
chronologically. Use additional sheets of paper to list additional employers.
A. Employer/Company:___________________________________________________________________________________
Immediate supervisor’s name and title: ____________________________________________________________________
If self-employed, provide the name of the rm or business: ____________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________
(include area code)
Title of your position: _________________________________________________
Your major responsibilities: _____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________ to ______________________ Hours per week: ___________ Total hours: ______________
Month/Year Month/Year
B. Employer/Company:___________________________________________________________________________________
Immediate supervisor’s name and title: ____________________________________________________________________
If self-employed, provide the name of the rm or business: ____________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________
(include area code)
Title of your position: _________________________________________________
Your major responsibilities: _____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________ to ______________________ Hours per week: ___________ Total hours: ______________
Month/Year Month/Year
Please list interior design projects which demonstrate your diversied interior design services experience. You must provide all docu-
mentation including drawings, schedules and specications for each project listed below in support of your application. Your applica-
tion cannot be processed until you have provided project documentation which you have personally prepared. Do not submit photos,
magazine articles or sample boards.
Project 1
A. Client’s name: __________________________________________________Telephone number: _____________________
(include area code)
Client’s address: _____________________________________________________________________________________
Street address City State ZIP code
B. Type of project: ________________________________________________________ Year completed: ________________
Location of project: __________________________________________________________________________________
Scope of work and services provided: ____________________________________________________________________
__________________________________________________________________________________________________
Your responsibilities on the project: ______________________________________________________________________
__________________________________________________________________________________________________
Project 2
A. Client’sname:__________________________________________________Telephonenumber:_____________________

(includeareacode)
Client’saddress:_____________________________________________________________________________________
Streetaddress City State ZIPcode
B.Typeofproject: ________________________________________________________ Yearcompleted:________________
Locationofproject: __________________________________________________________________________________
Scopeofworkandservicesprovided:____________________________________________________________________
__________________________________________________________________________________________________

Yourresponsibilitiesontheproject:______________________________________________________________________
__________________________________________________________________________________________________

Project 3
A. Client’sname:_________________________________________________ Telephonenumber:_____________________

(includeareacode)
Client’saddress:_____________________________________________________________________________________
Streetaddress City State ZIPcode
B.Typeofproject: ________________________________________________________Yearcompleted: ________________
Locationofproject: __________________________________________________________________________________
Scopeofworkandservicesprovided:____________________________________________________________________
__________________________________________________________________________________________________

Yourresponsibilitiesontheproject:______________________________________________________________________
__________________________________________________________________________________________________

__________________________________________________________________________________________________
Use additonal sheets of paper to list additional projects to demonstrate major experiences in all categories listed below.
CHECKLIST
Indicate your level of responsibility for projects 1, 2 and 3 above in each of the following categories: O = No Experience,
L=LimitedExperience,M=MajorExperience,NA=NotApplicable
Projects
1 2 3
Preparationofdrawings................................................................................................ _____ _____ ______
Administrationofdrawings.......................................................................................... _____ _____ ______
Preparationofschedules.............................................................................................. _____ _____ ______
Administrationofschedules......................................................................................... _____ _____ ______
Preparationofspecications......................................................................................... _____ _____ ______
Administrationofspecications................................................................................... _____ _____ ______
Non-loadbearingpartitions.......................................................................................... _____ _____ ______
Switchlocationandtype............................................................................................... _____ _____ ______
Outletlocationandtype................................................................................................ _____ _____ ______
Interiorconstructionnotmateriallyrelatedto
ormateriallyaffectingthebuildingsystems................................................................. _____ _____ ______
Furnishings................................................................................................................... _____ _____ ______
Layouts........................................................................................................................ _____ _____ ______
Cabinetry....................................................................................................................... _____ _____ ______
Fixtures........................................................................................................................ _____ _____ ______
Finishes........................................................................................................................ _____ _____ ______
Lightinglocationandtype............................................................................................ _____ _____ ______
Materials....................................................................................................................... _____ _____ ______
-6-
- 7 -
REFERENCES
• Please provide a total of three (3) references. Two (2) of the references must have known you for at least ve (5) years.
• Personal references from two people (do not use relatives).
• Your professional reference must be a state certied/licensed design professional such as an interior designer, architect or professional
engineer who has rst-hand knowledge of your work.
PERSONAL REFERENCES
1. Name: __________________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________
(include area code)
Occupation: _____________________________________________ Number of years you have known this person: _________
2. Name: __________________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________
(include area code)
Occupation: _____________________________________________ Number of years you have known this person: _________
PROFESSIONAL REFERENCE
1. Name: __________________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: ____________________________
(include area code)
Occupation: _____________________________________________ Number of years you have known this person: _________
ADDITIONAL RELEVANT INFORMATION
1. Are you a member of any professional organizations? Yes No
If “Yes,” please list the information requested below.
Name of organization Membership dates Ofce held/duties
a . __________________________________ _________________________ ______________________________
b . __________________________________ _________________________ ______________________________
c . __________________________________ _________________________ ______________________________
2. Are you involved in any community activities related to your interior design work?
Yes No
Name of activity, board or commission Ofce held Duties
a . __________________________________ _________________________ ______________________________
b . __________________________________ _________________________ ______________________________
c . __________________________________ _________________________ ______________________________
3. Please provide any additional information which you would like the Committee to consider in connection with this application.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
- 8 -
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the Interior Design Examination
and Evaluation Committee of the New Jersey State Board of Architects for certication under the provisions of Title 45
of the General Statutes of New Jersey and the Rules of the Interior Design Examination and Evaluation Committee, swear
(or afrm) that I am the applicant and that all information provided in connection with this application is true to the best of
my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed
sufcient to deny certication or to withhold renewal of or suspend or revoke a certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:3-31 et seq., together with the Rules and Regulations of the
Interior Design Examination and Evaluation Committee, N.J.A.C. 13:27-9.1 et seq., and fully understand that in receiving
certication from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for certication. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
Afx Seal Here
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
For ofce use only:
Qualications: Recommendations: Board Action:
Education _______ Interview _______ Interview _______ Date ______
Experience _______ Certify _______ Withhold _______ Date ______
Examination _______ Additional Certify _______ Date ______
Information _______
} ss.
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Application Checklist of Requirements for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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