Fillable CertifiCation and authorization form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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CertifiCation and authorization form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The CertifiCation and authorization form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 2 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 17 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Bureau of Securities
P.O. Box 47029
Newark, New Jersey 07101
CertifiCation and authorization form
for a Criminal history BaCkground CheCk
Directions:Pleasecompleteallofthesectionsonthisform.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName(ifapplicable)
2. Mailing
Address___________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode
3. E-mailAddress:____________________________________ InvestmentAdviser IssuerAgent
(You MUST use the mailing address on le as it appears on the Form U4. If this address is not current, please amend your Form U4
as soon as possible so that there is no delay in the background check process.)
4. Dateofbirth____/____/____5.Sex: Male Female6.Daytimetelephonenumber___________________
MonthDayYear (Includeareacode)
7. SocialSecuritynumber_____ /_____/ _____ 8.IndividualCRDorstateregistrationnumber________________________

9. Haveyoucompletedthengerprintingprocessby,'(0,$RUMorphoTrustfortheNew Jersey Bureau of Securities or
'LYLVLRQRIConsumer Affairs
sinceMay2012?<HV No
If“Yes,”pleaseprovidethedateonwhichyouwerengerprinted:____/____/________
MonthDayYear
If you were fingerprinted by,'(0,$RU MorphoTrust after May 2012 as part of the criminal history background
SURFHVVIRUregistration by the Bureau of Securities or the New Jersey Division of Consumer Affairs, you will not
be required to be ngerprinted a second time. However, a criminal history background check must be performed each
time you applyforregistration.
10. Haveyoueverbeenarrestedand/orconvictedofacrimeoroffense?(Minortrafcoffensessuchasaparkingorspeeding
violationsneednotbelisted.) Yes No
Every such conviction on record must be disclosed.
A true copy of every police report, judgment of
conviction, sentencing order and termination of probation order, if applicable, must be submitted with this form.
Any documents (including employer or supervisor letters of reference, if applicable) which present clear
andconvincingevidenceofrehabilitationmustbesubmittedwiththisform.
Note:
Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the
courtwherethoseorders,disposingoftheconviction,wereissuedandled.
It is your continuing responsibility to disclose convictions of crimes or offenses: You must notify the
BureauofSecuritieswithinthirty(30)daysifyouareconvictedofanycrimesoroffensesafterthisformhasbeencompleted.
Dr.
Mr.
Mrs.
Ms.
CertifiCation
 

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

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                  

             



 




frequently asked questions
I recently had a background check done for another New Jersey agency (e.g. the Department of Banking and Insurance).
Do I have to undergo the process again?


What if I previously completed the Certication and Authorization form and have gone through the Criminal History
Record Background Check process for the Bureau of Securities?
                 





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CertifiCation and authorization form (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 21 July 2020

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