New Jersey Office of the Attorney General
Division of Consumer Affairs
Occupational Therapy Advisory Council
124 Halsey Street, 6th Floor, P.O. Box 45037
Newark, New Jersey 07101
(973) 504-6570
Occupational Therapy Advisory Council
Certificate of Good Moral Character
Section to be completed by applicant.
Please print clearly.
______________________________________________________________________________________________________
Name of applicant
______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________
Telephone number (include area code)
To the Occupational Therapy Advisory Council
Section to be completed by reference.
This to certify that _________________________________________, being known to me personally, is of good moral character.
Therefore, I recommend this applicant for licensure as an Occupational Therapist/Occupational Therapy Assistant in the State of
New Jersey pursuant to N
.J.S.A. 45:9-37.51 et seq.
______________________________________________________________________________________________________
Name of reference (excluding family members)
______________________________________________________________________________________________________
Street address City State ZIP code
______________________________________________________________________________________________________
Professional title Relationship to applicant
I hereby certify that the foregoing statements made by me are true. I am aware that if the foregoing statements made by me are willfully
false, I am subject to punishment.
______________________________________________ ________________________________________
Signature (referene) Date
click to sign
signature
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