Fillable Home Improvement Contractor Application For Initial Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Home Improvement Contractor Application For Initial Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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NOTICE TO CONTRACTORS
*Please read this page carefully. This information is important.*
➤ The Contractor’s Registration Act requires that all home improvement contractors register
with the N.J. Division of Consumer Affairs and display their registration number listed,
NJHIC#, at the following places:
❑ within their places of business (the original registration certicate)
❑ in all advertisements
❑ on business documents, contracts and correspondence with consumers
❑ on all commercial vehicles.
➤ALL Home Improvement Contracts in excess of $500 and all changes in the terms and
conditions of the contract, must be in writing and are required to include, but are not limited
to:
❑ the legal name, business address, and contractor’s registration number, and the legal name
and business address of the sales representative
❑ a copy of the certicate of commercial general liability insurance for $500,000 per occurrence,
and the telephone number of the insurance agency issuing the certicate
❑ description of the work to be performed and principal products and materials to be used or
installed
❑ a statement of any guarantee or warranty with respect to any product, material, labor or
service made by the seller of home improvement
❑ description of any mortgage or security interest to be taken in connection with the nancing
or sale of the home improvement
❑ total price including nances charges
❑ signatures by all parties involved
❑ notice to the consumer in 10 -point bold-faced type as follows:
YOU MAY CANCEL THIS CONTRACT AT ANY TIME BEFORE MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER RECEIVING A COPY OF THIS CONTRACT. IF YOU WISH TO
CANCEL THIS CONTRACT, YOU MUST EITHER:
1. SEND A SIGNED AND DATED WRITTEN NOTICE OF CANCELLATION BY REGISTERED OR
CERTIFIED MAIL, RETURN RECEIPT REQUESTED; OR
2. PERSONALLY DELIVER A SIGNED AND DATED WRITTEN NOTICE OF CANCELLATION
TO:
(Name, address and phone number of contractor.)
If you cancel this contract within the three day period, you are entitled to a full refund of your money.
Refunds must be made within 30 days of the contractor’s receipt of the cancellation notice.
➤ Contractors should also make sure they have read through the Statutes and Regulations which
can be found on the Division’s home page www.nj.gov/oag/ca/HIC/HIC_stats.htm and which is
also contained in the original home improvement registration application package.
The New Jersey “Contractors’ Registration Act”
Frequently Asked Questions
Notice: The following questions and answers are intended for the convenience of contractors who may
be required to register under this Act. This should not be considered a legal document nor a complete
explanation of the law and should not be relied upon as such. The New Jersey Division of Consumer
Affairs (“the Division”) recommends that you consult an attorney if you need legal advice.
1. What is the Contractors’ Registration Act?
The “Contractors’ Registration Act” (the “Act”) establishes a mandatory registration program for
contractors who are in the business of selling or making home improvements in New Jersey.
2. What is a home improvement?
Any remodeling, altering, painting, repairing, renovating, restoring, moving, demolishing, or
modernizing of a structure used as a place of residence, or of any portion of the property on which
the structure is located, is considered a home improvement for the purposes of the Act.
Home improvement includes the construction, installation, replacement, improvement, or repair
of driveways, sidewalks, swimming pools, terraces, patios, landscaping, fences, porches, windows,
doors, cabinets, kitchens, bathrooms, garages, basements and basement waterproong, water
puriers (not including the installation or disconnection of water ltration systems), insulation
installation, siding, wall-to-wall carpeting or attached or inlaid oor coverings, and other changes,
repairs, or improvements made to residential property. Construction of a new residence is not
considered a home improvement under the Act.
3. Who is a home improvement contractor?
Any person, whether a sole proprietorship, partnership, corporation, limited liability company or any
other type of business organization that is engaged in the business of selling or making home
improvements is considered a home improvement contractor for the purposes of the Act.
4. Who must register?
The Act requires any contractor engaging in the business of making or selling home improvements,
whether an individually owned business or a corporation, limited liability company, partnership, or
association, to register annually with the Division, unless specically exempted from registration
under the Act.
5. I am a landscaper and I only mow lawns and trim shrubs. Must I register?
No. However, you must register if you plant owers, shrubs and trees or lay sod or establish a lawn.
6. What if I do not register?
Any home improvement contractor who is required to register but who has not received a registration
number by is prohibited from selling or making home improvements. Unregistered contractors
who continue to sell or make home improvements may be subject to civil penalties and
possibly criminal penalties as well.
7. How does registration affect my ability to obtain construction permits?
Effective January 1, 2006, municipalities are barred from issuing construction permits to an
unregistered home improvement contractor who is required to register.
NJ Ofce of the Attorney General
Division of Consumer Affairs
8. What do I need to do to become registered?
To become registered, a contractor must:
• Complete and submit an application on the form provided by the Division, including copies of all
documents required;
• Complete the Disclosure Statement page of the application;
• File proof that it has secured and maintains, in its name as the insured, a policy of commercial
general liability insurance in a minimum amount of $500,000 per occurrence; and
• Pay a fee of $110.00.
9. How do I obtain an application for registration?
Application forms are available online at the Division website. Copies of the application form may
be obtained by calling the Division at 1-888-656-6225, and are also available from construction
ofcials in most municipalities.
10. Is there a fee?
Yes. The nonrefundable fee is $110.00 payable to the Division.
11. My home improvement contracting business has been in operation for many years. Is it
“grandfathered,” or must it be registered?
All home improvement contractors must register, unless they are exempt. There is no provision for
grandfathering.
12. Once I become registered, how long will my registration be valid?
Once the initial registration has been obtained, it must be renewed before March 31 of each year.
Reminder notices are mailed to all registered home improvement contractors in January of each
year, with instructions about how to renew their registration.
13. I only do home improvement jobs “on the side.” Do I still have to register?
Yes. The Contractors’ Registration Act applies to any person, corporation, partnership or association
engaging in the business of making or selling home improvements — regardless of whether the
home improvements are done on a full-time or part-time basis.
14. I work for a home improvement contractor. Do I have to register?
Employees or ofcers of a registered home improvement contractor are not required to register with
the Division separately as long as any home improvement work they are doing is done on behalf of
the registered contractor. However, if the employee sells or makes home improvements “on the
side” or separate and apart from the work he or she does for the registered contractor, that person
must register with the Division separately.
15. I am a subcontractor of a home improvement retailer that has a net worth of more than
$50,000,000. Do I have to register?
Yes. A subcontractor of a home improvement retailer must register unless otherwise exempt.
However, a home improvement retailer with a net worth of at least $50,000,000 and employees of
such a retailer who are making or selling home improvements within the scope of their employment
are exempt from registration.
16. I am a subcontractor, paid by the general contractor, and never enter into a contract with the
consumer. Do I have to register?
Yes, a subcontractor of a contractor must register.
NJ Ofce of the Attorney General
Division of Consumer Affairs
17. I am a retail merchant with a net worth under $50,000,000 who sells retail products used in
home improvements. Do I have to register?
No.Youarenotrequiredtoregisterunlessyoualsochargefortheinstallationofthoseproducts.
For example, X carpet store sells wall-to-wall carpet. X carpet store does not have to register.
However,Ycarpetstoresellswall-to-wallcarpetandYstoreemployeesinstallthecarpet.Ycarpet
storemustregister.Zcarpetstoresellswall-to-wallcarpetandchargesthecustomerforinstallation
ofthecarpet.ZcontractswithJoeSmithtoinstallthecarpet;JoeSmithisnotanemployeeofZ
carpetstore.BothZcarpetstoreandJoeSmithmustregister.
18. I plan to help my cousin remodel her house. Do I have to register?
No.Theregistrationrequirementsdonotapplytoanypersonperformingahomeimprovementona
homeheorsheownsorthatisownedbyamemberofhisorherfamily.
19. Do I have to register if I am improving a home belonging to a charity or a non-prot corporation?
No.Apersonperforminghomeimprovementworkonaresidentialpropertyownedbyabonade
charityorothernon-protorganizationisnotrequiredtoregister.
20. I work exclusively on commercial properties. Do I have to register?
TheActappliesonlytoresidentialor“non-commercial”units—single-familyormulti-familyhomes—
orcommercialpropertiesthatarebeingconvertedtoresidentialor“non-commercial”units.Thelaw
doesnotapplytopropertiesthatarebeingusedforcommercialpurposes.
21. I am licensed as a home improvement contractor by a local town. Do I still have to register?
Yes.EffectiveJanuary1,2006,theActsupersedesanymunicipallaworregulationthatprovidesfor
thelicensingorregulationofhomeimprovementcontractors.However,contractorsmuststillobtain
constructionpermitsfromthemunicipalityinwhichthey’reworkingandmustsubmittoinspections
bymunicipalconstructioncodeofcials.
22. Do people who handle maintenance for community associations or co-ops have to register?
No. TheAct exempts from the registration requirements individuals employed by a community
associationorcooperativecorporation—commonlyreferredtoas“handymen,”superintendents
and/ormaintenanceworkers—whomakehomeimprovementswithinthescopeoftheiremployment
attheresidentialpropertyownedorleasedbythecommunityassociationorcooperativecorporation.
23. Do architects, heating, ventilating, air conditioning and refrigeration contractors, professional
engineers, landscape architects, land surveyors, electrical contractors, master plumbers,
locksmiths, burglar alarm businesses, re alarm businesses, new home builders, or
any other individuals or businesses that already hold licenses from the State of New Jersey
have to register?
No.Aslongasthelicenseeisactingwithinthescopeofhisorherprofession,heorsheisexempt
fromregistration.Forexample,anewhomebuilderdoesnothavetoregisterifitisconstructinga
newhome,butmustregisterifitisbuildinganadditionorrenovatinganexistingresidentialstructure.
24. If a business claims an exemption based on a license that may be issued only to individuals,
must an owner or principal of the business be one of the license holders?
Yes.Forexample,apumpinstaller'slicensecanonlybeissuedbyDEPtoanindividual.Ifaprincipal
ofadrillingcompanyislicensedasapumpinstaller,thecompanyisnotrequiredtoregisterasa
homeimprovementcontractor.However,ifadrillingcompanyemploysalicensedpumpinstaller
whoisnotaprincipalofthecompany,thecompanyisrequiredtoregister.
NJ Ofce of the Attorney General
DivisionofConsumerAffairs
25. Does the law apply to out-of-state contractors?
Anycontractorwhosellsormakesimprovementstohomesornon-commercialpropertiesinNew
Jersey must register with the Division — regardless of whether the contractor is based in New
Jerseyorsomeotherstate.
26. Are there penalties for not registering?
Any contractor who fails to register as required by the Contractors’ Registration Act but who
continuestosellormakehomeimprovementsorwhoviolatesanyothersectionofthelawissubject
tocivilmonetarypenaltiesofupto$10,000fortherstoffenseandupto$20,000foreachsubsequent
offense.Also,anyonewhoknowinglyviolatestheActisconsideredguiltyofacrimeofthefourth
degreeandfacesadditionalnesaswellaspossiblejailtime.
27. I was convicted of a crime in the past. Am I ineligible to become registered?
Notnecessarily.Noindividualwillbedisqualiedfromregistrationorhavehisorherregistration
revokedonthe basis ofanyconvictionifthat person candemonstratetothe Division clearand
convincingevidenceofthatperson’srehabilitation.TheDivision,indeterminingwhethersomeone
hasdemonstratedrehabilitation,mustconsiderthefollowing:
• thenatureandresponsibilityofthepositiontheconvictedindividualwouldhold;
• thenatureandseriousnessoftheoffense;
• thecircumstancesunderwhichtheoffenseoccurred;
• thedateoftheoffense;
• theageoftheindividualwhentheoffensewascommitted;
• whethertheoffensewasanisolatedorrepeatedincident;
• anysocialconditionswhichmayhavecontributedtotheoffense;and
• anyevidenceofrehabilitationincluding,amongotherthings,goodconductinprisonorinthe
community,counselingorpsychiatrictreatmentreceived.
28. What are some other regulatory requirements affecting contractors?
Contractorsarerequiredtocomplywiththeexistingregulations,includingtheuseofwrittencontracts
forhomeimprovementjobsthatcostmorethan$500.
29. Must I display my registration number?
Yes.TheActrequirescontractorstoprominentlydisplaytheirregistrationnumberswithintheirplaces
of advertisements, on business cards, on their commercial vehicles and on all business
documents,includingcontracts.
Rev.2/29/16
NJ Ofce of the Attorney General
DivisionofConsumerAffairs
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Ofce of Consumer Protection
Regulated Business Section
124 Halsey Street, 7th Floor, P.O. Box 46016, Newark, NJ 07101
Home Improvement Contractor Application for Initial Registration
Information that you provide on this application may be subject to public disclosure as required by the Open
Public Records Act (OPRA).
Instructions: Please print clearly, in ink and answer all of the questions. Your application will not be processed until all of the
questions have been answered and all of the required documents, and the registration fee, have been received by this Division. If
a question does not apply to your business, write “N/A.” Refer to: Instructions for Register as a HIC.
1. Business Name
The name must match the name listed on the corporate documents and the insurance certicate.
2(a). LIST ALL OTHER NAMES UNDER WHICH THE APPLICANT DOES BUSINESS .
2(b). IF YOU DO NOT USE ANY OTHER NAME(S), WRITE “NONE.” IF THE ANSWER TO THIS
QUESTION IS LEFT BLANK, IT
WILL AUTOMATICALLY DEFAULT TO “NONE.”
HIC-Form1-Rev. 9/22/16
Contact your local county
clerk’s ofce to obtain a Trade
Name Certicate.
Contact the N.J. Department
of the Treasury, Division
of Revenue, at (609) 292-9292,
if the business is a corporation.
Refer to the samples.
- 1 -
2(c). Indicate the type of business you own.
Sole Proprietorship: Attach a copy of the business’ Trade Name Certicate. Refer to Sample #1 or #2.
Partnership: Attach a copy of the business’ Trade Name Certicate. Refer to Sample #1 or #2.
Corporation:
Attach a copy of the business’ Certicate of Incorporation. Refer to Sample #3, #4 or #5.
Limited Liability Co.:
Attach a copy of the business’ Certicate of Formation. Refer to Sample #5, #6 or #7.
Limited Liability Partnership:
Attach a copy of your Certicate of Formation. Refer to Sample #5, #6 or #7.
Additional Requirements
Out-of-State Corporation: Attach a copy of the business’ New Jersey Certicate of Authority and the
formation documents from your home state. Refer to Sample #9.
Alternate Name: Attach a copy of the business’ Registration of Alternate Name Form C-150G. Refer to Sample #8.
☞
3. Business Address (Must be a street address.) E-mail Address:
City
State
ZIP Code
Telephone No.
Fax No.
(include area code)
(include area code)
4. Mailing
Address If the address is the same as in question #3, write “N/A.”
5. Agent –
If the business is a corporation (L.L.C., L.L.P., etc.), you must provide the name and address of an agent in New Jersey
who is authorized to accept documents on its
behalf for the service of process.
Agent’s Name
Street Address
City
State: New Jersey ZIP Code
T
elephone No.
Fax No.
(include area code)
(include area code)
Instructions for Registration as a
Home Improvement Contractor
Please print clearly, in ink and answer all of the questions. Your application will not be processed until all of the questions
have been answered and all of the required documents, and the registration fee, have been received by the Division. If a
question does not apply to your business, write “N/A.”
1. List the name of your business. This will be the name that appears on your registration.
If you are doing business under your own name, list your full legal name. For example, “John Doe.”
If you are doing business under a ctitious name, print your business name as it is listed on your Trade Name
Certicate.
For example, write “John Doe’s Painting & Carpentry.”
2.
Provide a copy of your Alternate Name Form C-150G or Trade Name Certicate. If you do not use any other names,
write “N/A.”
6. Provide proof that you have secured and maintain a policy of commercial general liability insurance in a minimum
amount of $500,000 for each occurrence. Acceptable proof must include an effective policy number, the date
of issuance, the effective date and your signature. Refer to the enclosed Sample #10.
7(a).
If you are a sole proprietor and answer “Yes” to question 7(a), the business’ registration will be denied until you provide
the Division with a written release issued by the lenders or guarantors stating that you have cured the default
or are making payments on the loan in accordance with a repayment agreement approved by the lender or guarantor.
7(b).
If you are a sole proprietor and answer “Yes” to question 7(b), the business’ registration will be denied until
you submit a certication from the court or the Probation Division that the conditions that resulted in the denial
have been satised.
7(c).
If you are a sole proprietor and not a U.S. citizen, submit a copy of your immigration documents.
8.
FEIN - If you are not sure whether your business requires a Federal Employer Identication Number (FEIN), call
609-292-9292 or call 1-800-829-4933. If you do not have a FEIN, you may now obtain one, on-line, at www.irs.gov.
Please allow time for your application to be processed, and for the business’ registration to be printed and mailed.
6.
Does the business have a certicate of liability insurance of at least $500,000 for each occurrence?
Yes No
You must attach your insurance certicate or your application will not be processed.
Refer to the enclosed insurance Sample #10.
Complete questions 7(a), 7(b) and 7(c) only if the business is run by a sole proprietor.
7(a).
Is the sole proprietor in default of a New Jersey or federal direct or guaranteed educational loan?
Yes No
If “Yes,” see the instructions. See Instructions
7(b).
Is the sole proprietor the subject of a child-support warrant or has the applicant failed to pay
Yes No
a court-ordered child-support obligation in an amount equal to or more than the amount of
See Instructions
child support payable for six months, failed to pay any court-ordered health care coverage
for the past six months or failed to respond to a subpoena relating to a paternity or
child-support proceeding?
If “Yes,” see the instructions.
7(c).
Check the appropriate box that indicates the sole proprietor’s citizenship/immigration status
.
U.S. Alien Other
citizen
Provide the business’ Federal Employer Identication Number and provide your
Social Security number.
8(a).
Federal Employer Identication Number (FEIN)
□ □ □ - □ □ □ - □ □ □
8(b). Social Security number □ □ □ - □ □ - □ □ □ □
*
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 Ofce of Consumer
Protection is required to obtain your Social Security number. Pursuant to these authorities, the Ofce of Consumer Protection
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; and
b. the Probation Division or any other agency responsible for child-support enforcement, upon request.
Lawfully admitted
for permanent
residence in U.S.
- 2 -
9. List the full name, home and business street address and business telephone number of each owner, ofcer, director,
principal and person with an ownership interest of
10 percent or more in the business and the percentage of ownership
held. If the applicant is a partnership, each member
of the partnership must be listed. (Use additional sheets of paper
if necessary.)
Please print clearly.
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address
City State ZIP code
_______________________________________________
Business telephone number (include area code)
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
______________________________________________________________________________
Name and title
_______________________________________________________________________________________________________
Business street address City State ZIP code
_______________________________________________________________________________________________________
Home street address City State ZIP code
_______________________________________________
Business telephone number (include area code)
- 3 -
You must indicate
Percentage of Ownership
____%
➦
You must indicate
Percentage of Ownership
____%
➦
You must indicate
Percentage of Ownership
____%
➦
10(a).
Is any ofcer, director, principal or person with an ownership interest of 10 percent or
Yes No
more in the business the holder of any professional or occupational license, certicate or
registration issued by any state or jurisdiction? If “Yes,” provide the following information:
10(b).
Has any action been taken against this license, certicate or registration?
Yes No
If “Yes,” please provide any supporting documentation and the outcome of the action.
11.
Have any of the business’ ofcers, directors, principals or persons with an ownership interest of 10 percent or more in the
business:
A. Violated or failed to comply with the provisions of any act, regulation or order
administered or issued by the New Jersey Division of Consumer Affairs?
Yes No
B. Entered into any consent order or assurance of voluntary compliance with the New
Jersey Division of Consumer Affairs or any other state or federal agency? or
Yes No
C. Been adjudged liable in an administrative or civil action in any state or federal agency
involving any of the following situations:
(i.) Obtaining a license, certicate or registration through fraud, deception or
misrepresentation?
(ii.)
Engaging in the use or employment of dishonesty, fraud, deception, misrepresentation,
false promise or false pretense?
(iii.) Engaging in gross negligence, gross malpractice or gross incompetence?
(iv.) Engaging in acts of negligence, malpractice or incompetence involving selling or
making a home improvement?
(v.) Engaging in professional or occupational misconduct? and/or
(vi.) Engaging in theft, fraud or deceptive business practices?
Yes No
11(a).
If you answered “Yes” to any part of question number 11, please provide the following:
Important Instructions:
For each occurrence listed above, please provide a true copy of all nal orders and/or judgments, consents and agreements. For the
purposes of this paragraph, a judgment of liability in an administrative or civil action shall include, but not be limited to, any nding
or admission that the business, or any of its ofcers, directors, principals or persons with an ownership of 10 percent or more in the
business engaged in an unlawful practice or practices related to any of the named situations C(i) through C(vi) above, regardless of
whether that nding was made in the context of an injunction, a proceeding resulting in the denial, suspension or revocation of a
license, certicate or registration, consented to in an assurance of voluntary compliance or any similar order or legal agreement
with any state or federal agency.
Holder’s Name
Name(s) of the agency that
issued the License, Certicate
or Registration
Type of License,
Certicate or Registration
License, Certicate
or Registration
Number
Date Issued
Date of Action
Name of applicant, partner(s),
person(s) or business against
whom action was taken.
Name and address of the
government agency that took
action against the individual
(applicant, partner, etc.)
Type of Action Taken
- 4 -
Disclosure statement
(Please print your business name and check either the “Yes” or “No” box below.)
Business Name: ____________________________________________________________________________________
Has the applicant or any of its ofcers, directors, principals or persons with an ownership of 10 percent or more in the
applicant been convicted of a crime involving moral turpitude, or any crime relating adversely to selling or making home
improvements or any crime in violation of any of the following provisions of the “New Jersey Code of Criminal Justice,”
Title 2C of the New Jersey Statutes, or the equivalent under the laws of any other jurisdiction?
1. Any crime of the rst degree;
2. Any crime which is a second- or third-degree crime and is a violation of chapter 20 or 21 of Title 2C of the New Jersey
Statutes; or
3. Any other crime which is a violation of N.J.S.A. 2C:5-1 (criminal attempt), 2C:5-2 (conspiracy), 2C:11-2 (criminal homicide),
2C:11-3 (murder), 2C:11-4 (manslaughter), 2C:12-1 (assault), 2C:12-3 (terroristic threats), 2C:13-1 (kidnapping), 2C:14-2
(sexual assault), 2C:15-1 (robbery), subsection a. or b. of 2C:17-1 (arson and related offenses), subsection a. or b. of 2C:17-2
(causing or risking widespread injury or damage), 2C:18-2 (burglary), 2C:20-4 (theft by deception), 2C:20-5 (theft by
extortion), 2C:20-7 (receiving stolen property), 2C:20-9 (theft by failure to make required disposition of property received),
2C:21-2 (criminal simulation), 2C:21-2.1 (fraud relating to driver’s license or other document issued by government agency
to verify identity or age; simulation), 2C:21-2.3 (fraud relating to motor vehicle insurance identication card; production
or sale), 2C:21-3 (frauds relating to public records and recordable instruments), 2C:21-4 (falsifying or tampering with
records), 2C:21-6 (frauds relating to credit cards), 2C:21-7 (deceptive business practices) 2C:21-12 (defrauding secured
creditors), 2C:21-14 (receiving deposits in a failing nancial institution), 2C:21-15 (misapplication of entrusted property and
property of government or nancial institution), 2C:21-19 (wrongful credit practices and related offenses), 2C:27-2 (bribery in
ofcial and political matters), 2C:27-3 (threats and other improper inuence in ofcial and political matters), 2C:27-5
(retaliation for past ofcial action), 2C:27-9 (public servant transacting business with certain persons), 2C:27-10 (acceptance or
receipt of unlawful benet by public servant for ofcial behavior), 2C:27-11 (offer of unlawful benet to public servant for
ofcial behavior), 2C:28-1 (perjury), 2C:28-2 (false swearing), 2C:28-3 (unsworn falsication to authorities), 2C:28-4 (false
reports to law enforcement ofcials), 2C:28-5 (tampering with witnesses and informants; retaliation against them), 2C:28-6
(tampering with or fabricating physical evidence), 2C:28-7 (tampering with public records or information), 2C:28-8
(impersonating a public servant or law enforcement ofcer), 2C:30-2 (ofcial misconduct), 2C:30-3 (speculating or wagering
on ofcial action or information), 2C:35-5 (manufacturing, distributing or dispensing a controlled dangerous substance),
2C:35-10 (possession, use or being under the inuence or failure to make lawful disposition of a controlled dangerous
substance), 2C:37-2 (promoting gambling), 2C:37-3 (possession of gambling records), 2C:37-4 (maintenance of gambling
resort).
If “Yes,” please provide the following:
Yes No
For each conviction, attach the following:
1. Judgment of conviction.
2. Sentencing order.
3. Presentencing report.
4. Letter conrming probation and/or parole status.
5. Documents showing clear and convincing evidence of rehabilitation, including letters or references from members of
your community who are not related to you by blood or marriage, and who can attest to your character.
6. Certicate of Rehabilitation pursuant to N.J.S.A. 2A: 168A-7 to 16.
Name of
person against whom
action was taken
Action Taken
Name and address of the
government agency that
took action
Nature of the
Offense
Date of Action
☞
- 5 -
Certification
I, as a principal ofcer of the business, understand that this application for registration will be accepted and the
registrationissuedonlyiftherequirementsoftheConsumerFraudAct(“Act”),N.J.S.A.56:8-137toN.J.S.A.56:8-152,and
theregulationspromulgatedundertheActhavebeenmet.
Icertifythatthebusinessandeachofitsofcers,directors,principalsandpersonswithanownershipof10percentor
moreintheapplicantarecapableofdischargingthefunctionsofaregistrantinamannerconsistentwiththepublic’shealth,
safetyandwelfare.
Icertifythatalloftheinformationprovidedinconnectionwiththisapplicationistruetothebestofmyinformation,
knowledgeand belief.Iunderstand thatany omissions,inaccuraciesor failureto makefulldisclosures maybedeemed
sufcient to deny registration or to withhold renewal of or suspend or revoke a registration issued by the Division of
ConsumerAffairs(“theDivision”).
IagreetocooperatefullywithanyrequestbytheAttorneyGeneralortheDivisiontoprovideanyassistanceorinformation
andtoproduceanyrecordsrequestedbytheDivision,andtocooperateinanyinquiry,investigationorhearingconductedby
theDivision.
Youmustcompleteallvelinesbelow.
_________________________________________
Businessnameofapplicant
_________________________________________
Yourname(pleaseprintclearly)
_________________________________________
Yoursignature
_________________________________________
Yourtitle
_________________________________________
Date

Any changes, additions or deletions to the information you have provided must be submitted to the address listed below
within 20 days.
Please submit:
(1)Acompletedapplication–allofthequestionsmustbeanswered.
(2)Anonrefundablecheckormoneyorderintheamountof$110.00madepayabletotheN.J.DivisionofConsumerAffairs.
(3)ProofofinsurancerequiredbyN.J.A.C.13:45-17-12.6.RefertoSample#10.Thecerticateofinsurancemustalsoreect
 thebusiness’ctitiousname(s)oralternatename(s)ifany.
(4) Attachthecorporatedocument(s).
(5) Attachanyotherdocumentsrequiredbyquestions#7(a),7(b),7(c),10(a)and11(a),andtheDisclosureStatement.
Mailing Address: State of New Jersey
Division of Consumer Affairs
Regulated Business Section
Home Improvement Unit
124 Halsey Street, 7th Floor
P.O. Box 46016
Newark, NJ 07101
Ifyouneedaduplicateorreplacementregistration,thefeeis$20each.MakethecheckpayabletotheNewJerseyDivisionof
ConsumerAffairs.
- 6 -
N.J. TRADE NAME CERTIFICATE
CERTIFICATE OF INCORPORATION
Page 1 Page 2
OUT-OF-STATE TRADE NAME CERTIFICATE
Note: The appearance of
these documents may vary
depending on the state and
county of origin.
SAMPLE FORMS
Page 1 Page 2
Sample #1 Sample #2
Sample #3 Sample #3
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 7 -
CERTIFICATE OF INCORPORATION
SAMPLE FORMS
SHORT FORM STANDING
Page 1 Page 2
Sample #4 Sample #4
Sample #5
Note: Sole Proprietor and Partnership documents are
issued by your local county clerk’s oce.
Certicate of Formation and Certicate of Incorporation
documents are issued by the State of New Jersey.
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 8 -
CERTIFICATE OF FORMATION
SAMPLE FORMS
CERTIFICATE OF FORMATION
Page 1 Page 2
Page 1 Page 2
Sample #6 Sample #6
Sample #7 Sample #7
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
For information on documentation issued by another state or jurisdiction, contact the issuing authority for a copy of the document(s).
- 9 -
CERTIFICATE OF LIABILITY INSURANCE
REGISTRATION OF ALTERNATE NAME CERTIFICATE OF AUTHORITY
SAMPLE FORMS
Sample #8 Sample #9
Sample #10
For information on documentation issued by the State of New Jersey call 609-292-9292 or visit www.state.nj.us/njbgs .
For information on a Trade Name Certificate issued in New Jersey contact your local county clerk’s office.
- 10 -
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Home Improvement Contractor Application For Initial Registration (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 16 July 2020

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