Fillable Forensic Nurse-Certied Sexual Assault (FN-CSA) Certicate Instructions for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Forensic Nurse-Certied Sexual Assault (FN-CSA) Certicate Instructions for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Forensic Nurse-Certied Sexual Assault (FN-CSA) Certicate Instructions for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 7 pages long and contains:

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  • 47 check-boxes
  • 90 other fields

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New Jersey Ofce 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
www.njconsumeraffairs.gov/nur/Pages/applications.aspx
Instructions for Reinstatement of an Expired
Forensic Nurse-Certied Sexual Assault (FN-CSA) Certicate
An FN-CSA whose certicate has been administratively suspended for nonpayment of a biennial renewal
fee may be reinstated by the Board upon completion of the following:
• Payment of the current and immediately preceding biennial renewal fees pursuant to
N.J.A.C. 13:37-5.5(e);
• Submission of an afdavit of employment listing each job held during the period the certicate was
suspended, including the name, address and telephone number of each employer; and
• If the FN-CSA has not paid a reinstatement fee for licensure as a registered professional nurse
within the same biennial period, the FN-CSA shall pay, in addition to the renewal fees, the
reinstatement fee from N.J.A.C. 13:37-5.5(e).
Complete and return to:
New Jersey Board of Nursing
P.O. BOX 45010
Newark, NJ 07101
Attn: Forensic Nurse Department
Notarized Application
Application Fees: $300.00
(Reinstatement Application Fee: $100.00 + $100 Payment for both the current biennial renewal
period and the immediately preceding biennial renewal fee)
Certication of Employment
New Jersey Ofce 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
www.njconsumeraffairs.gov/nur/Pages/applications.aspx
Application to Reinstate an Expired Certicate
Along with the submission of this completed application, all fees must be paid in the form of a check or money order made out
to the State of New Jersey (Reinstatement Instruction Sheet). The fee(s) must be submitted with this application for reinstatement
(applicants should understand that if the fee is paid with a personal check, and the check is returned by the bank due to
insufcient funds, the next step in the reinstatement process will be delayed until the fee is paid).
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 (by putting a check in the appropriate box). 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.
Information that you provide on this application (including your address of record) may be subject to public disclosure as
required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: ________________________
Month Day Year
1. Name _________________________________________________________________________________________________
Last name First name Middle initial Maiden name
2. Address
Home: _____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ___________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months, with your
name printed on the back of the
photo.
A photo is required with each
application.
Do not use staples to attach the
photo.
3. *Social Security No: ____ - ____ - ____
You must provide your Social Security number to the Board. Failure to do so will result in denial of licensure reinstatement.
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child
Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board
is required to obtain your Social Security number. Pursuant to these authorities, the Board is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the
purpose of reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certificates to U.S.
citizens or qualied aliens. To comply with this federal law, check the appropriate box below which indicates your
citizenship/immigration status. If you are not a U.S. citizen, attach a copy of your alien registration card (front and back) or
other documentation issued by the U.S. Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be
directed to the USCIS at: 1-800-375-5283.
5. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the
entity that issued your student loan, for the eventual repayment of the loan. You will not be able to obtain
a license or certicate unless you provide the required documents concerning the plan for repayment of your student loan.
6. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?
Yes No
b.
Have you failed to provide any court-ordered health insurance coverage during the past six months?
Yes No
c.
Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding?
Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to questions a(1) through d will result in a denial of
reinstatement of licensure. Furthermore, any false certication of the above may subject you to a penalty, including, but
not limited to, immediate revocation or suspension of licensure.
_________________________________ __________________________________________ ___________________
Applicant’s name (please print) Applicant’s signature Date
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signature
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7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
8. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.)
Yes No
9. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of
guilty, non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
10. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. _________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expire
11. Have you ever been disciplined or denied a nursing license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
12. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
13. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any
agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
14. Have you ever been named as a defendant in any litigation related to the practice of nursing or other professional practice
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
17. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of nursing or other professional practice in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 11 through 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
CertifiCation for reinstatement appliCation
I, ________________________________________________ , in making this application to the Board or Committee
for reinstatement of my certificate or registration, certify that I am the applicant and that all of the information
provided in connection with this application is true to the best of my knowledge and belief. I understand that any omissions,
inaccuracies or failure to make full disclosures may be deemed sufcient to deny reinstatement or to withhold renewal of or
suspend or revoke a license or registration issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for reinstatement. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
_____________________________________________________________ ___________________________________
Signature of applicant Date
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signature
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New Jersey Ofce 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
www.njconsumeraffairs.gov/nur/Pages/applications.aspx
Employment Certication for the Reinstatement of
an Expired Certicate
Directions:Pleasecompletethiscertication,signanddateitandreturnittotheNewJersey
BoardofNursing.Ifyouhavehadmorethantwoemployers,pleaseaddadditionalsheetsofpaper
withtheemploymentdata.TheBoardmaycontactyouremployer(s)toverifyyouremployment.
____________________________________________________________________________
Firstname Middlename Lastname Maidenname
____________________________________________________________________________
PresentStreetAddress City State ZIPCode
 R.N. LicenseNo.___________________________
F.N.-CSA CerticateNo._________________________
Employment Data: (For the past ve (5) years in New Jersey or in any other jurisdiction.)
1. _________________________________________________________________________
Nameofemployingagencyorfacility
_________________________________________________________________________
Streetaddress
_________________________________________________________________________
City State ZIPCode
_________________________________________________________________________
JobTitle EmploymentDates:FromTo
_________________________________________________________________________
Supervisor’sname  Title TelephoneNo.(includeareacode)
2. _________________________________________________________________________

Nameofemployingagencyorfacility
_________________________________________________________________________
Streetaddress
_________________________________________________________________________
City State ZIPCode
(Sign and date reverse side)
_________________________________________________________________________
JobTitle EmploymentDates:FromTo
_________________________________________________________________________
Supervisor’sname  Title TelephoneNo.(includeareacode)
_________________________________ ________________________________ ______________________
Applicant’s name (Please print) Applicant’s signature Date
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signature
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Forensic Nurse-Certied Sexual Assault (FN-CSA) Certicate Instructions for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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