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

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Application for Mortuary Jurisprudence Examination (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 Mortuary Science of New Jersey
124 Halsey Street, 6th Floor, P.O. Box 45009
Newark, New Jersey 07101
(973) 504-6425
Application for Mortuary Jurisprudence Examination
Applications should be led prior to the 1st day of the month in which the examination is held.
This form may not be photocopied in blank or used by anyone else.
A nonrefundable application ling fee of $125.00, 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 Board is to be immediately notied of any address change. It is recommended that you contact the Board ofce concerning your status
if you have not received your admission credentials one week after the submission of the prescribed fee and the examination application.
I, the undersigned, hereby make application for admission to the Mortuary Jurisprudence Examination scheduled to be held
___________________________________________, 20 _____ .
Please type or print clearly. You must answer all of the questions on this application. Date of birth:________________________
Month Day Year
Name ____________________________________________________________________________ ( _______________________ )
Last name First name Middle initial Maiden name
Address ____________________________________________________________________________________________________
Street City State ZIP code County
Telephone No. ___________________________ E-mail address _____________________________________________________
(include area code)
1. Have you ever been on active duty with the Armed forces? Yes No
If “Yes,” attach “Discharge Papers” or “ Notice of Separation Form.”
Yes No
2. 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.
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.)
3. 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
4. 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
5. 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
If the answer to any of the above questions, numbers 2 through 5, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
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
Sworn and subscribed to before me this __________
day of _________________________ , 20 _______
Month Year
__________________________________________
Name of Notary Public (please print)
__________________________________________
Signature of Notary Public
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Application for Mortuary Jurisprudence Examination (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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