New Jersey Office of the Attorney General
Division of Consumer Aairs
Director’s Oce
124 Halsey Street, 7th Floor, P.O. Box 45027
Newark, New Jersey 07101
(973) 504-6534
Certification Form for Applicants
with no Social Security Number or Individual Taxpayer ID Number
Complete forms should be emailed to the Board or Committee you are applying to.
The email address may be found on your Board or Committee website at www.njconsumeraffairs.gov.
Address: ____________________________________________________________________________
Street City State ZIP code
Home phone: ____________________________ Cell phone: _____________________________
(include area code) (include area code)
Email address: ________________________________________________________________________
License type you are seeking: ____________________________________________________________
I, _____________________________________ born on ____________________ arm the following:
(Print full legal name) (Month/Day/Year)
• I have never been issued a Social Security Number;
• I am not eligible for a Social Security Number; and
• I have never been issued an Individual Taxpayer Identication Number.
By signing this adavit, I declare that the above information is true to the best of my knowledge. I am
aware that if any of the information provided by me is willfully false, I am subject to punishment.
____________________________________ ______________________________
Applicant signature Date
click to sign
signature
click to edit
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