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

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

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  • 59 check-boxes
  • 179 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Mortuary Science of New Jersey
124 Halsey Street, 6th Floor, P.O. Box 45009
Newark, New Jersey 07101
(973) 504-6425
Application for Intern Registration
Date: _______________________________
A nonrefundable application fee of $50 and a refundable registration of $75 (total of $125), 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. You are, however, 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
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
For Ofce Use Only
Applicant #: ______________________
Preceptor license #: ________________
Intern #: _________________________
Photo #1
Photo #2
Attach two clear, full-face pass-
port-style photographs (2˝x 2˝)
of your head and shoulders, taken
within the past six months.
Two photographs are required
with each application.
Do not use staples to attach the
photographs.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so may result in denial/nonrenewal of
licensure.
*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 may result in a denial of
licensure. 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. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous 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 this question 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 application. 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 on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“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
365 days, whichever is longer.
“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. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
______________________________________________ _______________________________
Applicant’s signature Date
click to sign
signature
click to edit
7. 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
8. 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.)
9. 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
_____________________ _______________________ ____________________________ ____________________
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
10. 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
11. 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
12. 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
13. Have you ever been named as a defendant in any litigation related to the practice of mortuary science or other professional or
occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a
professional or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. 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
16. 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 mortuary science 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 10 through 16, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
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? The ofcialtranscript fromeach college or
universityyouhaveattendedmustbesubmitteddirectlytotheBoardofce.Pleasehaveeachcollegeoruniversityforwarddirectly
totheBoardtheofcialtranscript.
_______________________________________________________________________________________________________
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. Listallofthedegreesthatyouhavereceivedfromrecognizedcollegesoruniversities.Pleasehaveeachcollegeoruniversityforwarddirectly
totheBoardtheofcialtranscriptforeachdegreethatyouhaveearned.
Degree,
Educational Inclusive Diplomaor  Date
institution years Certicate Major granted
____________________________ _______ _____________ ______________________ _______________
____________________________ _______ _____________ ______________________ _______________
____________________________ _______ _____________ ______________________ _______________
____________________________ _______ _____________ ______________________ _______________
Record Release Authorization
6. IntheeventthatIdonotmaintaintheacademicstandardsrequiredofaninternwhileconcurrentlyattendingcollegeduringmy
internship:
I authorizetheBoardtoreleaseacopyofmytranscriptandotherpertinentinformationtomypreceptorandconcernedparties.
Signed:____________________________________________________
do
donot
Professional Education
7. Please ll out this section if you have completed, or if you are currently attending, mortuary school.
a. ___________________________________________________________________________________________________
School’s name Street address
__________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________ _________________________ _________________
Type of program (one-year, associate degree or other) Date of enrollment Number of credits in program
____________________________ ______________________________
Date of graduation Number of certicate or degree
b. __________________________________________________________________________________________________
School’s name Street address
__________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________ _________________________ _________________
Type of program (one-year, associate degree or other) Date of enrollment Number of credits in program
____________________________ ______________________________
Date of graduation Number of certicate or degree
c. ___________________________________________________________________________________________________
School’s name Street address
__________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________ _________________________ _________________
Type of program (one-year, associate degree or other) Date of enrollment Number of credits in program
____________________________ ______________________________
Date of graduation Number of certicate or degree
National Board Examination
8. Have you taken the National Board Examination given by the International Conference of Funeral Service Examining Boards Inc?
Yes No
If “Yes,” complete the following:
Date(s) taken Score(s)
______________________________________________________________________ ________________________
______________________________________________________________________ ________________________
______________________________________________________________________ ________________________
______________________________________________________________________ ________________________
______________________________________________________________________ ________________________
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 State Board of Mortuary
Science of New Jersey for certication, licensure or registration under the provisions of Title 45 of the General Statutes
of New Jersey and the Rules of the State Board of Mortuary Science of New Jersey, 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,
licensure or registration or to withhold renewal of or suspend or revoke a certicate, license or registration issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:7-32 et seq., together with the Rules and Regulations of the State Board of
Mortuary Science of New Jersey, N.J.A.C. 13:36-1.1 et seq., and fully understand that in receiving certication, licensure
or registration 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, licensure or registration. 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 _________________________ , 20_______
Month Year
__________________________________________
Name of Notary Public (please print)
__________________________________________
Signature of Notary Public
Afx seal here
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Mortuary Science of New Jersey
124 Halsey Street, 6th Floor, P.O. Box 45009
Newark, New Jersey 07101
(973) 504-6425
Intern Registration
(This section is to be completed by the preceptor.)
Please print or type.
1. Providethenameandaddressofthefuneralhomewheretheapplicantwillberegistering.
_______________________________________________________________________________________________________
Nameoffuneralhome Telephonenumber(includeareacode)
_______________________________________________________________________________________________________
Streetaddress City State ZIPcode
2. Preceptor’sname: ______________________________________ Licensenumber:____________________________________
a. HaveyouheldanactiveNewJerseylicenseforthepasttwoyears? Yes No
b. Inthepastveyears,haveyoubeenconvictedofacrimeoroffenserelatingadverselytothepracticeofmortuaryscienceora
crimeofmoralturpitude? Yes No
If“Yes,”pleaseexplain:
c. Inthepastveyears,haveyoubeenthesubjectofdisciplinaryactiontakenbyaprofessionalboardresultinginthesuspension,
revocationorsurrenderofalicenseortheplacementofsignicantlimitiationsonsuchlicense? Yes No
If“Yes,”pleaseexplain:
3. Areanyotherinternscurrentlyregisteredattheestablishment? Yes No
If“Yes,”pleaseprovidetheirnames.
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
4. Whatwasthefuneralcasevolumeforthepreviousyear(stillbirthsexcluded)? __________________________
5. Howmanyhoursperweekwilltheapplicantwork? Minimum_______________ Maximum ________________
6. Listbelowtheapplicant’sregularweeklyworkschedule.
7. Brieyoutlinethevariousdutiesthatwillbeexpectedoftheapplicant:
SundayMonday TuesdayWednesdayThursday Friday Saturday
a.m.
p.m.
8. Does the funeral home perform an adequate amount of embalmings so the applicant can successfully fulll his/her requirements
on-time? Yes No
If “No,” please indicate the name of the funeral home and licensee who will assist the preceptor with obtaining required amount
of embalmings (75). Please attach to the application an acceptance letter from the licensee who will be training the applicant in
embalming.
Name of funeral home _____________________________________________________________________________________
Name of licensee ______________________________________________
I certify that I, ______________________________________will be responsible for all necessary training to successfully prepare
Print name
the applicant to become a licensed practitioner of mortuary science, explained the duties outlined above to the intern applicant, and
have read the rules regarding internship and preceptor requirements at N.J.A.C. 13:36-2.
________________________________________________________
Signature of preceptor
Sworn and subscribed to before me this __________
day of _________________________ , 20_______
Month Year
__________________________________________
Name of Notary Public (please print)
__________________________________________
Signature of Notary Public
Afx seal here
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Application for Intern Registration (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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