Fillable Application to Reactivate an Inactive Electrical Contractors License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application to Reactivate an Inactive Electrical Contractors License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 37 check-boxes
  • 169 other fields

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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 to Reactivate an Inactive Electrical Contractor’s License
You may not practice in the State of New Jersey until your license or certificate has been reactivated.
N.J. License No.:______________________________________ Type of License: _______________________________________
Initial License Date: ________________________________ Date License Became Inactive: _____________________________
Please submit with this application a check or money order for $150.00 made payable to the State of New Jersey, for the current
triennial licensure period. (Applicants should understand that if the fee is paid with a personal check, and the check is returned
by the bank due to insufficient funds, the next step in the reactivation 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 (including your address of record) 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
1. Name _________________________________________________________________________________________________
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
- 1 -
3. *Social Security No: ____ - ____ - ____
You must provide your Social Security number to the Board. Failure to do so will result in denial of licensure or registration
reinstatement/reactivation.
*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
isrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoard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 certificates to U.S. citizens or qualified 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 office 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 certificate unless you provide the required documents concerning the plan for repayment of your student loan.
6. 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 reactivation of licensure or registration. Furthermore, any false certification of the above may subject you to a penalty,
including, but not limited to, immediate revocation or suspension of licensure or registration.
_________________________________ __________________________________________ ___________________
Applicant’s name (please print) Applicant’s signature Date
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7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certificate, divorce decree or court order.
8. 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
9. 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 finding 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.)
10. Do you currently hold, or have you ever held, a professional license or certificate 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 certificate held, provide the date(s) held and the number(s). If the license or certificate was issued under
a different name, please provide that name. _________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expire
11. Have you ever been disciplined or denied a professional or occupational license or certificate of any kind in New Jersey, any
other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever had a professional or occupational license or certificate of any type suspended, revoked or surrendered in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
13.
Has any action (including the assessment of fines or other penalties) ever been taken against your professional or occupational practice
by any agency or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
14. Have you ever been named as a defendant in any litigation related to the practice of electrical contracting or other professional
or occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. Are you aware of any investigation pending against a professional or occupational license or certificate issued to you by a
professional board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. 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
17. 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 electrical contracting 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 11 through 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 3 -
Employment since your license was placed in inactive status. (You may photocopy this page if necessary.)
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
_________________________________________ ________________________________________ ______________________
Applicant’s name (Please print) Applicant’s signature Date
Yes
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Continuing Education
Please list all of the courses that you have successfully completed since your license expired. (N.J.A.C. 13:31-1.7 requires
that 34 credit hours of continuing education be successfully completed for a license to be reactivated. Ten of those credits
must be acquired by means of a course of study relating to the most recent edition of the National Electrical Code. Review
the above-cited regulation to learn all of the details regarding continuing education requirements.) Please submit copies of
your continuing education certicates with your application.
Date Title Subject Matter Sponsor No. of Hours
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
- 5 -
CertifiCation for reaCtivation appliCation
I, ________________________________________________ , in making this application to the Board for reactivation
of 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 sufficient to deny reactivation or to withhold renewal of or suspend or revoke a 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 qualifications for reactivation. I further authorize all institutions, employers, agencies and all governmental
agencies and instrumentalities (local, state, federal or foreign) to release any information, files 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.
_____________________________________________________________ ___________________________________
Signature of applicant Date
- 6 -
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Application to Reactivate an Inactive Electrical Contractors License (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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