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

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

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Application Instructions/Checklist
Use this checklist to determine whether you have complied with all of the requirements for licensure in New Jersey as an
Athletic Trainer. Once your application has been received, a le will be established and you will be notied concerning any
missing documents.
Application Fee: Please enclose a nonrefundable check or money order in the amount of $100.00 made
payable to the State of New Jersey and mail it with your application to the: State Board of Medical Examiners,
Athletic Training Advisory Committee, 140 East Front Street, 3rd Floor, P.O. Box 183, Trenton, New Jersey 08625.
The fee for initial licensure is $80.00 if paid during the rst year of a biennial renewal period or $40.00 if paid during
the second year of a biennial renewal period.
Supply a resume which includes a full employment history.
Answer all of the questions on the application form.
Attach a clear, full-face passport-style photograph of your head and shoulders to the front page of the application. Please
sign and print your name along with the date on the back of the photograph.
Enter your Social Security number. (If you do not have a S.S.N. when you are applying for a license, you must obtain
one prior to being issued a permanent license number. You must provide a copy of your Social Security card. You should
print your name and provide your signature on the bottom of the photocopy.)
All applicants who have had a name change since Athletic Training school must submit legal documentation.
Have your college/university provide an official transcript in a sealed envelope. Have the college/university
forward the transcript(s) directly to the Committee’s ofce.
Make photocopies of the Verication of State License form and mail it to each state in which you hold (or have held)
a license. The board in each state where you are or have been licensed must ll out the form, stamp it with the
board’s ofcial seal and mail it directly to the: State Board of Medical Examiners, Athletic Training Advisory
Committee, 140 East Front Street, 3rd Floor, P.O. Box 183, Trenton, New Jersey 08625. Please contact
each state ofce for the necessary processing fees for verication before mailing out your verication forms.
Verication of Professional Employment Form - Please forward a copy of this form to every employer for whom you
have worked in a professional capacity since graduation from your Athletic Training program. The employer should be
directed to return this form directly to the Committee ofce at the address shown on the form. Forms submitted to the
Committee by the applicant will not be accepted.
If you have previously taken the BOC examination, please have your ofcial BOC verication sent directly to the
Committee ofce at: State Board of Medical Examiners, Athletic Training Advisory Committee, P.O. Box 183,
Trenton, New Jersey 08625. You may reach the Board of Certication at (402) 559-0091 or send your request to 4223
South 143
rd
Circle, Omaha, Nebraska 68137-4505. You may also contact the BOC at their Web site: www.bocatc.org.
Revised 3/14/16
Please use additional sheets of paper if you cannot t all of your information in the space provided on this form. Make a
notation by each question that more information has been attached. Please mark your attached answers with the same number
corresponding to the question that you are answering.
If you answer “Yes,” to any of the child-support questions, please attach to this application a written explanation on a
separate sheet of paper.
Fill out the Medical Conditions section on this application.
Fill out the Certication and Authorization form for a criminal history background check and mail it with the application
to the Committee.
Once the entire application has been completed, have it signed and stamped/sealed by a notary public.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Dear Applicant:
New Jersey law (N.J.S.A. 45:1-30 et seq.) requires that every person seeking licensure as a health care professional must
undergo a Criminal History Record Background Check. An important part of this process is the recording of each applicant’s
ngerprints.
In order for the Division to conduct a Criminal History Record Background Check, you must complete and return the
enclosed Certication and Authorization form. Once the application and Certication and Authorization form have been
received and processed, you will be sent instructions about the ngerprinting process.
Please be advised that the Criminal History Record Background Check must not be older than six months at the time you
are to be licensed. If the application process extends for more than six months from the date the Criminal History Record
Background Check was conducted, the Division will be required to conduct a new F.B.I. background check. A fee for this
service is required.
Please send all completed information to:
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor,
P.O. Box 183
Trenton, New Jersey 08625
Thank you for your cooperation.
The Athletic Training Advisory Committee
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Athletic Training Application for Licensure
Date : ____________________________
A nonrefundable application ling fee of $100.00, in the form of a check or money order made out to the State of New Jersey, must
be submitted with this application (applicants should understand that if the application ling 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
Place of birth: ________________________
City State Country
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.
PA-94-1
Page 1 of 6
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;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
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. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license unless you provide the
required documents concerning the plan for repayment of your student loan.
6. Child Support (You must answer a, b, c, and d.)
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.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
Page 2 of 6
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signature
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7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the denitions carefully. Your
responses will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you have
reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert
the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good faith. If
you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the applica
tion.
Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against self-incrimination.
You should be aware, however, that you may later be directed by the Attorney General to answer a question that you have refused
to answer on the basis of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory
law. (N.J.S.A. 45:1-20.)
“Ability to practice as an athletic trainer” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of an athletic trainer, and to learn and keep abreast of
professional developments; and
b. The ability to communicate those judgments and related information to athletes and other interested parties, with or without the
use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of an athletic trainer, with or without the use of aids or devices, such as
corrective lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
dia
betes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather,
it means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the
previous two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroin or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or
not taken in accordance with the directions of a licensed health care practitioner.
a.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Committee will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you are
not eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
Page 3 of 6
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8. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
9. 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.) Yes No
Yes No
10. 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.
explanation. (Attach additional sheets of paper to this application.)
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
Yes No
If “Yes,”when and where? __________________________________________________________________________________
Have you previously applied for a license as an athletic trainer in New Jersey, any other state, the District of Columbia or in any
other jurisdiction?
11.
No
Do you currently hold, or have you ever held, a professional or occupational license or certicate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes
12.
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license was issued under a
different name, please provide that name. _____________________________________________________________________
First name Middle initial Last name
_____________________ _______________________ ____________________________ ____________________
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
Yes No
If “Yes,”list the date of issuance and expiration and the jurisdiction where the temporary license or limited permit was granted.
jurisdiction?
13. Have you ever held a temporary license or limited permit in New Jersey, any other state, the District of Columbia or in any other
__________________________________________________________________
14. Have you ever been cited for disciplinary reasons or denied a professional or occupational license or certicate of any kind in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. Have you ever had a professional or occupational 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
16. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational
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
17. Have you ever been named as a defendant in any litigation related to the practice of athletic training or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
18. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a professional
or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
19. 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
20. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional or
occupational group related to the practice of athletic training or other professional or occupational 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 14 through 20, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Page 4 of 6
Education
1. What is the name and address of the high school you attended? _____________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. What years did you attend high school? _____________________
3. Did you graduate from high school? Yes No
If “Yes,” what was the date of your graduation? ______________________________
Month Year
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
______________________________________________
Date certicate was issued
4. What is the name and address of the colleges or universities you have attended?
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
5. List all of the degrees that you have received from recognized colleges or universities. Please have each college or university forward
to the Committee the ofcial transcript for each degree that you have earned.
Educational institution Inclusive years Degree, Major Date granted
Diploma or
Certicate
______________________ ____________ ____________ ___________ _______________________
______________________ ____________ ____________ ___________ _______________________
______________________ ____________ ____________ ___________ _______________________
6. List the date of every BOC examination you have taken:
________________________________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Page 5 of 6
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 Athletic Training Advisory
Committee for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules
of the New Jersey State Board of Medical Examiners for the Athletic Training Advisory 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
licensure or certication or to withhold renewal of or suspend or revoke a license or certicate issued by the Committee.
I further swear (or afrm) that I have read N.J.S.A. 45:9-37.35 et seq., together with the Rules and Regulations of the Athletic
Training Advisory Committee, N.J.A.C. 13:35-10.1 et seq., and fully understand that in receiving licensure or certication
from the Committee, 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 licensure or 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 Committee.
_____________________________________________
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
} ss.
Page 6 of 6
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Verication of State License
A separate form must be used for each state.
(This form may be reproduced.)
Name of applicant: _____________________________________________________________________________________
Last name First name Middle initial
The above-named applicant is a licensee of the State of _______________________________________________ and was
issued a license number ________________________________________ on _____________________________________ .
Month Day Year
The applicant was licensed by the following:
BOC Examination: __________________________________________________________
Endorsement/Reciprocity from the State of: _________________________________________________________________
Other: ______________________________________________________________________
The license status is:
Current and in good standing expiring on: _______________________ . Revoked or suspended: ______________________
Date Date
Inactive/expired on: _______________________ Other (please attach explanation)
Date
The licensee does does not have a record of disciplinary history with this agency. (Attach disciplinary information, if
applicable.)
I hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record of the individual
on this form.
_______________________________________________________
Name of Board
_______________________________________________________
Name of person completing this form
_______________________________________________________
Title
_______________________________________________________
Signature
_______________________________________________________
Date
Board Seal
Form SV1
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Employment Verication Form
Applicant’s name: _____________________________________________________________________________________
Last name First name Middle initial
Employer’s name: _____________________________________________________________________________________
Employer’s address: ____________________________________________________________________________________
Street City State ZIP code
Employer’s telephone number: _______________________________________
include area code
1. What position did this Athletic Trainer hold when employed by you? ________________________________
2. What were the dates of employment for this Athletic Trainer? From: ______________ to: _______________.
3. Did this Athletic Trainer leave your employment in good standing? Yes No
4. Was this Athletic Trainer on probation, suspended or in any way
sanctioned/disciplined while employed by you? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5. Was this Athletic Trainer granted a leave of absence while employed by you? Yes No
6. Were any restrictions placed on this Athletic Trainer’s activities which were not
placed on all other employees holding similar positions? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
7. Were any formal staff complaints ever led against this Athletic Trainer? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8. Were any incident reports led involving the professional conduct or behavior of
this Athletic Trainer? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
P.O. Box 46017
Newark, New Jersey 07101
(973) 504-6414
CertifiCation and authorization form
f
or a Criminal history BaCkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
MonthDayYear 
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check
conducted for the Department of Education, another state agency or another state does not apply) you will not be required to
be ngerprinted a second time. However, the Division must perform a criminal history background check each time you apply
for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or money
order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Continuation on the reverse side ➨
Mr.
Mrs.
Ms.
BoardorCommittee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
DualLicense
LicenseType1
________________________
Applicant’sNumber
________________________
LicenseType2
________________________
Applicant’sNumber
________________________
CertifiCation
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the 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licensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
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 or licensure. 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orCommittee.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
__________________________________________________________ _________________________________

SignatureofapplicantDate
Rev. 1/2/19
9. Was this Athletic Trainer ever subject to nonroutine monitoring while in
your employment? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
10. Was this Athletic Trainer removed from the schedule for cause? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
11. Was this Athletic Trainer subject to nonroutine quality assessment review? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
12. Did quality assessment review of this Athletic Trainer ever result in a negative nding? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
13. Were any malpractice actions led naming this Athletic Trainer as a defendant based
on actions during his/her period of employment by you? Yes No
If “Yes,” please explain. ____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
14. Would you consider rehiring this Athletic Trainer? Yes No
Please print the name of the person/employer supplying information:_______________________________
Signature of the person/employer supplying information: ________________________________________
Date form was completed: _____________________
Please attach a letterhead from the facility where the applicant worked or supply some form of identication such as a
business card for the individual supplying this information.
Please return directly to: State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor
P. O. Box 183
Trenton, NJ 08625
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Application InstructionsChecklist (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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