Fillable Application for Certication as a Psychoanalyst (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for Certication as a Psychoanalyst (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Application for Certication as a Psychoanalyst (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 9 pages long and contains:

  • 6 signatures
  • 72 check-boxes
  • 115 other fields

Country of origin: US
File type: PDF

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DRAFT
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Certied Psychoanalysts Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45050
Newark, New Jersey 07101
(973) 504-6479
Application for Certication as a Psychoanalyst
Date:
Anonrefundableapplicationlingfeeof$100,intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbe
submittedwiththisapplicationforcertication.(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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
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
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placeofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
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
 Mr.
1. Name Mrs._____________________________________________________(___________________ )
Ms.
Lastname Firstname Middleinitial Maidenname
Dr.
2. Address:
Home:_____________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
_______________________________ _____________________________
Telephonenumber(includeareacode) E-mailaddress
 Employment:________________________________________________________________________
Nameofemployer 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 photograph is required with
eachapplication.
Donot use staplesto attach the
photograph.
For Board Use Only
Date received:
________________________
DRAFT
3. SocialSecurityNumber
Youmustprovide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Committeeisrequiredto
obtainyourSocialSecuritynumber.Pursuanttotheseauthorities,the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orcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. 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
DRAFT
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cationwillbeprocessedif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 a psychoanalyst”istobeconstruedtoincludeallofthefollowing:
a. The cognitive capacity to exercise reasonable psychoanalytic judgments and to learn and keep abreast of professional
developments;and
b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtopatients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apsychoanalyst,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certicateholder,
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thenature,theseverityandthedurationoftherisksassociatedwithanongoingmedicalconditionso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.
____________________________________________________ ___________________________________
Applicant’ssignature Date
click to sign
signature
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DRAFT
8. 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 Nonon vult, nolo contendere, no contest, or a nding of guilt by a judge or jury.
9. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
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
10. 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. ____________________________________________________________________
First name Middle initial Last name
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
_____________________ _______________________ ____________________________ ____________________
State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate Number
_____________________ _______________________ ____________________________ ____________________
State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate Number
_____________________ _______________________ ____________________________ ____________________
State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate Number
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
11. 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
12. 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
13. 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
14. Have you ever been named as a defendant in any litigation related to the practice of psychoanalysis or other professional
practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. 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
16. 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
17. Have you ever been sanctioned by or is any action pending before any employer, professional association, professional society, or
other professional group related to the practice of psychoanalysis 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 11 through 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
DRAFT
Education
1. Listeverycollegeoruniversityyouhaveattended.Thenindicatethedegreesyouhaveearned(bothundergraduateandgraduate).
Please have eachcollege oruniversity granting the qualifying master’s or higher degreeforward tothe Committeethe ofcial
transcript(s).
Educational institution Inclusive years Degree Major Date granted
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
2. Listthenamesandaddressesofthepsychoanalyticinstitutesyouhaveattended.Pleasehavetheinstitutegrantingcerticationforward
directlytotheCommitteetheofcialtranscriptandofcialproofofaccreditationoftheinstituteduringthetimetheapplicantwas
enrolledorvericationfromtheinstituteofitsrequirementofgraduatesfornumberofpatientcontacthours,numberofhoursunder
psychoanalytic supervision, number of personal psychoanalytic hours and number of credit hours of classroom instruction.
(N.J.A.C.13:42A-2.1(a)4.orN.J.A.C.13:42A-2.2(a)2.)
Name of Psychoanalytic institution Address
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________ ________________________________________________
__________________________________ ________________________________________________
DRAFT
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 Certied Psychoanalysts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
CertiedPsychoanalysts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 readN.J.S.A. 45:14BB-1 et seq., together with the Rules and Regulations of the Certied
PsychoanalystsAdvisoryCommittee,N.J.A.C.13:42A-1.1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educational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.
__________________________________________________
Applicant’ssignature
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.
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signature
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signature
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DRAFT
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Certied Psychoanalysts Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45050
Newark, New Jersey 07101
(973) 504-6479
Certicate of Good Moral Character
To the candidate: Please send one copy of this form to two character references and ask them to
return this form directly to the Committee ofce at the above address.
ThiscertiesthatIampersonallyacquaintedwith__________________________________________________________________
 (Pleaseprint)
of______________________________________________________________________________________________________ and
(Homeorbusinessaddress)
thatIknowhimorhertobeofgoodmoralcharacter.IherebyrecommendhimorhertotheCertiedPsychoanalystsAdvisoryCommittee
topracticeasapsychoanalystintheStateofNewJerseypursuanttolaw.
Pleaseprintyourname:_____________________________________________________
Signyourname: __________________________________________________________
Address: ________________________________________________________________
Relationshiptoapplicant:___________________________________________________
** Note: This form should not be completed by a relative or signicant other.
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New Jersey Office of the Attorney General
Division of Consumer Affairs
Certied Psychoanalysts Advisory Committee
P.O. Box 45050
Newark, New Jersey 07101
(973) 504-6479
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
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Application for Certication as a Psychoanalyst (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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