New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Social Work Examiners
124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101
(973) 504-6495
www.njconsumeraffairs.gov/sw
Duplicate License Form
Please complete this form and return it to this office, together with the $25.00 fee. Please submit
a check or money order, payable to the State of New Jersey.
Please check one: Lost Destroyed Misplaced Stolen Never Received
Name: ____________________________________________________________________________________
License number: ____________________________________________________________________________
Address of record: __________________________________________________________________________
Mailing address: ____________________________________________________________________________
Date of birth: _______________________________________________________________________________
Telephone number (include area code): ________________________________________________________
E-mail address: _____________________________________________________________________________
___________________________________________ ______________________________
Signature Date
The Board maintains, as part of its responsibilities, a record of your home address, business address and mailing
address. You may choose which of these addresses will be considered your “address of record.” If you do not indicate
which address should be used as your public address of record, your mailing address will be considered your address
of record. *A Post Ofce Box may be used as your address of record, but only if you provide another address which
includes a street, city, state and ZIP code.
click to sign
signature
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