New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Certied Homemaker-Home Health Aide
Employer Registration Form
Congratulations on your recent New Jersey licensure/registration. If you will employ Certied Homemaker-
Home Health Aides (CHHHAs), please complete this form and mail it, along with a copy of your agency’s
license/registration, to the New Jersey Board of Nursing. By doing this, you will be added to the Division of
Consumer Affairs’ list of CHHHA employers. As an employer of CHHHAs, you will be required to create and
regularly access an online account that will enable you to create and maintain a current list of CHHHAs in
your agency’s employ. Instructions regarding this online account will be e-mailed to you once this form has
been processed by the Division of Consumer Affairs, New Jersey Board of Nursing.
Agency Name: ______________________________________________________________________________
Agency Address 1: ___________________________________________________________________________
City: ________________________________________ State: _________________ ZIP code: _______________
Agency Address 2: ___________________________________________________________________________
City: ________________________________________ State: _________________ ZIP code: _______________
License/Registration Number: ____________________________________
Agency Registered with: (Please choose one.)
Department of Health and Senior Services
Department of Community Affairs
Regulated Business
Other
If other, please specify:________________________________________________________________________
Contact Name:___________________________________________Title:_______________________________
Contact Phone:________________________________
(include area code)
Contact E-Mail Address:___________________________________________________
Mail or fax this completed form to (973) 648-6914, along with a copy of your license/registration, to:
New Jersey Board of Nursing
124 Halsey Street, 6th oor
P.O. Box 45010
Newark, NJ 07101
Attention: Virginia Burks
Complete and return this form ONLY if your agency or facility employs Certied Homemaker-Home Health Aides.
You may contact Virginia Burks at the New Jersey Board of Nursing at (973) 273-8045 with any questions.
