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

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Application for Reinstatement/Reactivation Instructions (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 105 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Application for Reinstatement/Reactivation
Instructions
In accordance with the Uniform Enforcement Act, a professional or occupational license or certicate of registration
may be reinstated, provided that the applicant otherwise qualies for licensure, registration or certication and
complies with the provisions of N.J.S.A. 45:1-7.4. The necessary application and materials for applying for
reinstatement/reactivation are enclosed.
1. Complete: The enclosed application for reinstatement/reactivation.
2. Enclose:
• Payment of the unpaid renewal fee for the previous biennial renewal period (if applicable) and payment of
the current renewal fee;
• Payment of a reinstatement/reactivation fee (see N.J.A.C. 13:41-3.2 for Fee Schedule.); and
• Employment data listing the work performed while the professional planning license was suspended/
inactive. This is to include information on projects worked on or completed and the name of your immediate
supervisor.
3. An individual whose license has been suspended or on inactive status for a period more than ve years shall
successfully complete the State Part Examination which is required for initial licensure as a licensed Professional
Planner. (See N.J.S.A. 13:41-5.5 License Issuance; Renewal)
4. Submit to:
State Board of Professional Planners
P.O. Box 45016
Newark, NJ 07101
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Application for Reinstatement/Reactivation
Date: __________________________________
Along with the submission of this completed application, the reinstatement fee of $200.00 and the appropriate renewal fee must
be paid in the form of a check or money order made payable to the State of New Jersey. (Applicants should understand that if the
fees are 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 Country
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
Check one:
I am applying to have my license
to practice:
Reinstated
Reactivated.
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
photo.
3. Social Security Number
You must disclose your Social Security number to the Board or Committee. Failure to do so may 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 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 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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6. 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
7. 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.)
8. Have you previously applied for a license or certicate as a professional planner in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
If “Yes,” when and where? _________________________________________________________________
9. 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.
Is this license or
certicate active?
_________________ ___________________ ___________________________ _________________ Yes No
Type of license / certicate Number State that issued the license or certicate Date issued
_________________ ___________________ ___________________________ _________________ Yes No
Type of license / certicate Number State that issued the license or certicate Date issued
_________________ ___________________ ___________________________ _________________ Yes No
Type of license / certicate Number State that issued the license or certicate Date issued
_________________ ___________________ ___________________________ _________________ Yes No
Type of license / certicate Number State that issued the license or certicate Date issued
_________________ ___________________ ___________________________ _________________ Yes No
Type of license / certicate Number State that issued the license or certicate Date issued
10. Have you ever been disciplined or denied a professional planner’s license or certicate or any other professional license or certicate
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
11. 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
12. 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
13. Have you ever been named as a defendant in any litigation related to the practice of professional planning or other professional
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 license or certicate issued to you by any professional 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 group
related to the practice of professional planning 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 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.
__________________________________________________________________
Last name First name Middle initial
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Employment During Period of Suspended/Expired License
Please complete this certication, sign and date it and return it to the State Board of Professional Planners.
______________________________________________________________________________ ( ______________________ )
First name Middle name Last name Maiden name
_______________________________________________________________________________________________________
Current street address City State ZIP code
License number: ____________________________________
Are you currently working as a professional planner, or did you work as a professional planner while your license was lapsed or expired?
Yes No
Provide an explanation:
Employment data (For the past ve (5) years in New Jersey or in any other jurisdiction. You may photocopy this page if necessary.)
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Dates of employment ________________________ to _______________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Dates of employment ________________________ to _______________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Dates of employment ________________________ to _______________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Dates of employment ________________________ to _______________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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signature
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CertifiCation for
reinstatement/reaCtivation appliCation
I, _______________________________________________________ , in making this application to the Board for reinstatement/
reactivation of 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 reinstatement/reactivation or to withhold renewal of or suspend or revoke a certicate or license issued
by the Board.
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 reinstatement/reactivation. 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.
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.
___________________________________ ______________________________________________
Date Signature of applicant
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signature
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Application for ReinstatementReactivation Instructions (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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