New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Duplicate License Form
for Professional Planners
Please complete this afdavit, have it notarized and return it to this ofce, together with the appropriate fee. Please submit a check
or money order payable to the State of New Jersey, in the amount of $25.00. (Licensees should understand that if the fee is paid
with a personal check, and the check is returned by the bank due to insufcient funds, the next step in the process will be delayed
until the fee is paid.)
This is to verify that my license to practice as a Professional Planner for the current renewal cycle has never been voluntarily
surrendered, revoked, or suspended by the State Board of Professional Planners, but has been:
Please check one:
Lost Destroyed Misplaced Stolen
Never received.
I hereby request that a license be issued for the current renewal cycle.
Name:
_____________________________________________________________________________________________
License No.: ________________________________________
Address of record: ____________________________________________________________________________________
Mailing address: _____________________________________________________________________________________
Date of birth: ______________________________
Telephone No.: ____________________________(please include area code)
Email address: _______________________________________________________________________________________
I hereby certify that the foregoing statements made by me are true and correct. I am aware that if any of the foregoing statements
made by me are wilfully false, I am subject to punishment.
Sworn and subscribed to before me this _______ _____________________________________
day of ___________________________ 20____
_______________________________________
Signature of Notary Public
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. 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.
Licensee’s signature
Afx seal here
click to sign
signature
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click to sign
signature
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