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

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Application for Examination (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
Board of Examiners of Electrical Contractors
124 Halsey Street, 6th Floor, P.O. Box 45006
Newark, New Jersey 07101
(973) 504-6410
Application for Examination
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 application process will be delayed until the fee is paid.)
The Board maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You may choose
which of these addresses will be considered as your “address of record.” If you do not indicate (by putting a check in the appropriate box)
which address should be used as your address of record, your mailing address will be considered to be your address of record. A post ofce
box may be used as your address of record, but only if you provide another address which includes 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
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
photograph.
Date of photograph:
________________________
Month Day Year
3. SocialSecurityNumber
IfyouwereissuedaSocialSecurityNumberoranIndividualTaxpayerIdenticationNumber,youmustprovideittotheBoardor
Committee.Failuretodosomayresultindenialoflicensure/certication/reinstatement/reactivation.
*SocialSecurityNumber: __________-__________-__________
*IndividualTaxpayerIdentication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Enforcement
Law,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeisrequiredto
obtainthisinformation.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovidethisinformationto:
(For healthcare-related boards, the following a, b and c entries apply. For boards not related to healthcare, only the a and b
entries apply.)
 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 anAmerican citizen, please enclose a copy of your birth certificate or U.S. passport. 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(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thearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespond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throughdmayresultin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
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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 electrician” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of an electrician and to learn and keep abreast of occupational
developments; and
b. The ability to communicate those judgments and related information to clients 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 electrician, 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 occupation 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 occupational
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 Board 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
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signature
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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
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete explanation.
(Use additional sheets of paper if necessary.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
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. 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.)
11. 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 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
12. Have you ever been disciplined 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
13. 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
14. 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
15. Have you ever been named as a defendant in any litigation related to the practice of an electrician or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. 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
17. 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
18. 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 an electrician 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 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
19. Please provide proof of your practical experience working with tools in compliance with the National Electrical Code. (It is necessary
for you to submit a Work Experience Certication for each employer.)
a. Do you have a bachelor's degree in electrical engineering or technology? Yes No
(Please be aware of the fact that a bachelor's degree can be used to fulll three years of the ve-year experience requirement
needed to be certied as an electrical contractor in New Jersey. The remaining two years' experience must be of a hands-on
nature.) (You must submit a copy of your diploma with this application.)
b. What is the total number of years of your work experience in electrical installation and/or construction? __________
What is the average number of hours that you worked per week? _________
c. Have you attended a technical trade school or an approved apprenticeship course? Yes No
If "Yes," please provide the name of the technical trade school or approved apprenticeship course. _____________________
How many hours per week did you attend the technical trade school or approved apprenticeship course? _________________
d. Please indicate the total number of years that you attended the school or course.
From _______________________________to _____________________________ .
month/year month/year
You must submit a copy of each Certicate of Completion you have earned.
20. Detailed Statement of Experience (Please note: All experience must be in compliance with the National Electrical Code.):
Give a detailed account of your experience in electrical construction and installation, giving dates, employer(s)
and your duties for a minimum of the past ve years. (Please attach the completed Work Experience Certication
for each employer.) (Use additional sheets of paper if necessary.)
21. Application Fee
The application fee of $100.00 must accompany this form. Only checks or money orders, payable to the State of New Jersey, will
be accepted. (The application fee is nonrefundable.)
Dates
Month/Year
to
Month/Year
Employer Duties
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 Board of Examiners of Electrical
Contractors for certication or licensure under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the Board
of Examiners of Electrical Contractors, 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 licensure or to withhold renewal of or suspend or revoke a certicate or license issued
by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:5A-1 et seq., together with the Rules and Regulations of the Board of Examiners
of Electrical Contractors, N.J.A.C. 13:31-1.1 et seq., and fully understand that in receiving certication or licensure 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 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.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this ______________
day of _________________________ , _____________
______________________________________________
Name of Notary Public (please print)
______________________________________________
Signature of Notary Public
} ss.
Afx Seal Here
Month Year
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Application for Examination (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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