Fillable Application for NJ Professional Engineers Instructions for Completing (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application for NJ Professional Engineers Instructions for Completing (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 Professional Engineers and Land Surveyors
Home Inspection Advisory Committee
124 Halsey Street, 3rd Floor, P.O. Box 45043
Newark, New Jersey 07101
(973) 504-6233
Instructions for Completing an Home Inspector Licensure
Application for NJ Professional Engineers
Please read the following information carefully before completing an application for licensure as a Home Inspector.
If you previously held a Home Inspector’s license in New Jersey, DO NOT complete this application. You must complete an application
for reinstatement/reactivation.
Please visit the Committee’s website at www.njconsumeraffairs.gov/hom/Pages/default.aspx for information concerning licensing
requirements.
1. Complete the application for Home Inspector Licensure for NJ Professional Engineers is available at:
www.njconsumeraffairs.gov/pels/Pages/applications.aspx . Answer ALL of the questions.
2. Sign the application in the presence of a notary public (Page 8). Your application must be notarized or it will be returned to you
which will delay the process.
3. Attach (2) two clear, full-face original color passport-style photographs (2” x 2”) of your head and shoulders taken within the past six
months. (Photocopies and seles are not acceptable.)
4. Complete the Training and Experience portions on the Board-approved form attached to the application. The Board will not
accept any other form.
5. If you are applying by comity, provide written verication of licensure in good standing from all states in which you are licensed.
6. If you are a legal alien or have other immigration status, please submit your USCIS immigration documents. (Submit a copy of both
the front and the back of your card.)
7. Submit criminal history documents (if applicable).
8. Submit copies of all disciplinary actions taken against your professional land surveyor’s license(s) in any other jurisdiction (if
applicable).
9. Please submit a nonrefundable application fee in the form of a check or money order, payable to the State of New Jersey, in the
amount of $125.00.
10. Once your application has been fully approved by the Board, you will receive a License Activation Form. Please complete this
form and submit a license fee in the form of a check or money order, payable to the State of New Jersey, in the amount stated
on the License Activation Form.
Please submit all of the above-referenced documents to:
State Board of Professional Engineers and Land Surveyors
Home Inspection Advisory Committee
124 Halsey Street, 3rd Floor
P.O. Box 45043
Newark, New Jersey 07101
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
Home Inspection Advisory Committee
124 Halsey Street, 3rd Floor, P.O. Box 45043
Newark, New Jersey 07101
(973) 504-6233
Home Inspector Licensure Application for NJ Professional Engineers
Date: NJ Professional Engineers License Number: _________________________
A nonrefundable application ling fee of $125, in the form of a check or money order made payable 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: ________________________
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
Application number:
_________________________
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.
Rev. 9/26/18
- 1 -
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)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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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
-2-
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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 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
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 engineering, home inspection 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 certication 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 home inspection 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.
- 3 -
Proof of Insurance
N.J.S.A. 45:8-76 requires that every “licensed home inspector who is engaged in home inspection shall secure, maintain and le with
the board proof of a certicate of an error and omissions policy, which shall be in a minimum amount of $500,000 per occurrence. Every
proof of an error and omissions policy required to be led with the board shall provide that cancellation or nonrenewal of the policy shall
not be effective unless and until at least 10 days’ notice of intention to cancel or nonrenew has been received in writing by the board.”
______________________________________________________ _____________________________________________
Name of agent Name of insurance company
____________________________________________________________________________________________________________
Street City State ZIP code County
________________________________ _______________________________________ ____________________________
Telephone number (include area code) Policy number Expiration date
Employment Record
Current Employment
Employee Owner Shareholder
a. ________________________________________________________________________________________________________
Name of company or private practice Street address
________________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________________________________________________________________________
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from ______________________ to ______________________ __________________________
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities: ________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Previous Employment Employee Owner Shareholder
b. ________________________________________________________________________________________________________
Name of company or private practice Street address
________________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________________________________________________________________________
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from ______________________ to ______________________ __________________________
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities: _________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Employee Owner Shareholder
c. ________________________________________________________________________________________________________
Name of company or private practice Street address
________________________________________________________________________________________________________
City State ZIP code Telephone number (include area code)
________________________________________________________________________________________________________
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from ______________________ to ______________________ __________________________
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities: _________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________
- 4 -
- 5 -
Training
Please provide information regarding your training in each of the following areas prior to your becoming licensed as a pro-
fessional engineer: Structure Components, Exterior Components, Roong Systems, Plumbing Systems, Electrical Systems,
Heating Systems, Cooling Systems, Interior Components, Insulation Systems, Ventilation Systems, Fireplace Systems, Solid
Fuel Burning Appliances or Systems and Related Residential Housing Component Systems. (Use additional sheets of paper
if necessary.)
Experience
Please provide information regarding your experience in each of the following areas after you received your license as a
professional engineer: Structure Components, Exterior Components, Roong Systems, Plumbing Systems, Electrical Sys-
tems, Heating Systems, Cooling Systems, Interior Components, Insulation Systems, Ventilation Systems, Fireplace Systems,
Solid Fuel Burning Appliances or Systems and Related Residential Housing Component Systems. (Use additional sheets
of paper if necessary.)
- 6 -
- 7 -
Other Information (optional)
In the space below, please provide any other information that you would like the Committee to consider. You may provide
information concerning other licenses you have been issued in other states or jurisdictions. You may also provide character
or professional references. (Use additional sheets of paper if necessary.)
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 Home Inspection 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 Home Inspection 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. 45:8-61 et seq., together with the Rules and Regulations of the Home
Inspection Advisory Committee, N.J.A.C. 13:40-15.1 through 13:40-15.23, 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, agen-
cies 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.
- 8 -
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Application for NJ Professional Engineers Instructions for Completing (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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