Fillable Initial Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Initial Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 69 check-boxes
  • 123 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/default.aspx
Initial Applicant Checklist - Certied Homemaker-Home Health Aide
Please place a check mark next to each category, sign and date this checklist when submitting with
your application.
Name of Applicant: ______________________________________________
Social Security Number: _______ - ________ - ________
____ Review instruction sheet
____ Ofcial Application for Licensure. Answer all questions where indicated. (pages 2-6)
____ Immigration documentation included if applicable (question number 7, page 3)
____ Notarized Afdavit is complete along with Original 2”x2” color passport photo included
and signed (page 7)
____ Certication and Authorization for a Criminal History Background Check
(Signed, dated and notarized, pages 8 and 9)
____ Supporting court documents attached if applicable
____ All required fees are included along with a check or money order only (page 13)
ALL QUESTIONS MUST BE FILLED IN WITH THE APPROPRIATE ANSWER OR THE
LETTERS N/A (NOT APPLICABLE). DO NOT LEAVE ANY BLANK ANSWERS OR YOUR
APPLICATION WILL BE RETURNED.
I have completed all of the above items.
Signature________________________________
Date ____________________________________
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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/default.aspx
Instructions for Homemaker-Home Health Aide Certication
Please read the following information carefully before completing an application for homemaker-
home health aide (HHA) certication.
If you previously held HHA certication in New Jersey, DO NOT complete this application.
You must contact the Certied Homemaker-Home Health Aide Renewal Department in order to
complete the Application for Reinstatement.
1. Complete an application for HHA Initial Certication. Answer ALL of the questions.
2. Sign the application in the presence of a notary public.
3. Attach a clear, full-face original passport photograph (2” x 2”) of your head and shoulders
taken within the past six months. Sign your name on the front of the picture. (Photocopies
and seles are not acceptable.)
4. If you are a naturalized U.S. citizen, please submit a copy of your U.S. passport or certicate
of naturalization.
5. If you are a legal alien or have other immigration status, please submit your USCIS
immigration documents. (Submit a copy of both the front and the back of your card.)
6. Complete the Certication and Authorization question (Question 15).
7. Submit criminal history documents (if applicable).
8. Submit a check or money order for your application and certication fees. The application
fee of $50.00 is nonrefundable. The certication fee is based on the date your application is
led. (See page 15).
9. You will receive digital ngerprint information via regular mail. Please schedule your
appointment as soon as possible.Homemaker-Home Health Aide Unit at 973-792-4218
or the Board of Nursing Call Center at 973-504-6430, Monday through Friday, between
the hours of 8:30 a.m. and 4:30 p.m.
10. If your criminal background check results reveal no convictions for disqualifying offenses
or other crimes, you will be certied. If your criminal background results reveal convictions
for disqualifying offenses or other crimes, your application must be reviewed by the Board’s
disciplinary committee and will be delayed.
11. Please notify the Board of any change of address or change in your contact information.
- 1 -
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/default.aspx
Application to Become a Certied Homemaker-Home Health Aide
Directions: Answer all of the questions on both sides of this application and certication. Attach a recent passport-style photograph to the
designated spot on the last page of this form.
In order to complete the criminal history review process, you must complete a Certication
Authorization form and obtain electronic ngerprinting. The necessary forms needed to obtain the electronic ngerprinting, which will
initiate the criminal history background check, will be provided by the Board of Nursing. However, it is your responsibility to schedule an
appointment for the ngerprinting.
This application and certication must be signed and notarized. You must attach a check or money
order, made payable to the New Jersey Board of Nursing, to cover the cost of the application and certication. Please be advised that
the application fee is nonrefundable. The certication fee is refundable. (Applicants should understand that if the application ling
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 licensure 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 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
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Home telephone number _______________________________ Cellular telephone number ____________________________
(include area code) (include area code)
Social Security number ________________________________ E-mail address _____________________________________

(SeeItemnumber6onnextpage.)
3. Have you ever changed your name? Yes No (Please submit proof of legal name change.)
4. Date of birth __ __ /__ __ /__ __ Sex: Male Female Place of birth _____________________________
Month Day Year City State or Country
If you are a foreign-born/naturalized U.S. citizen, please submit your U.S. passport OR certicate of naturalization.
5. Height __________________ Weight _______________ Eye color ________________ Hair color _______________________
- 2 -
120-Day Period:
Begins __________________
Ends____________________
Ofcial Use Only
Board of Nursing
Candidate’s Number
________________________
If you have ever held certication
as a homemaker-home health
aide in New Jersey, you should
not fill out this application.
You should instead ll out the
Application for Reinstatement
of a Homemaker-Home Health
Aide Certication which may be
obtained from the Board.
________________________
Please note that your criminal history
background check must be complet-
ed within the 120-day conditional
certification period. If this is not
accomplished, your conditional
certication will be terminated.
6. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*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 Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee 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.
7. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates 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 ofce of 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.
8. 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.
9. 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 any of the questions a(1) through d will result in a denial of
licensure or certication. 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 or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Signature of applicant Date
- 3 -
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10. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the denitions carefully. Your
responses will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you have
reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert
the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good faith. If
you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the applica
tion.
Your application for licensure will be processed if you claim the Fifth Amendment privilege against self-incrimination. You should
be aware, however, that you may later be directed by the Attorney General to answer a question that you have refused to answer on
the basis of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory law. (N.J.S.A.
45:1-20.)
“Ability to practice as a certied homemaker-home health aide” is to be construed to include all of the following:
a. The cognitive capacity to exercise reasonable homemaker-home health care judgments and to learn and keep abreast of professional
developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without the
use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of a homemaker-home health aide, with or without the use of aids or devices, such
as corrective lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
dia
betes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather,
it means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the
previous two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroin or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or
not taken in accordance with the directions of a licensed health care practitioner.
a.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you are not
eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
- 4 -
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11. Which of the following provided your training as a homemaker-home health aide?
Home Health Care Agency or Firm School
Date course began _________ / _________ Date course completed _____________ / _________
Month Year Month Year
12. If a Home Health Care Agency or Firm provided your training, please complete the following:
Agency _________________________________________________________________________________________________
Address ________________________________________________________________________________________________
Street City State ZIP code County
13. If a school provided your training, please complete the following:
School _________________________________________________________________________________________________
Address _______________________________________________________________________________________________
Street City State ZIP code County
14. Please provide the name, address, and telephone number of the Agency or Health Care Service Firm that will employ you
in New Jersey.
Agency or Firm __________________________________________________________________________________________
Address ________________________________________________________________________________________________
Street City State ZIP code County
Telephone number __________________________________
(include area code)
Crimes and Offenses
A person shall be disqualied from certication if that person’s criminal history record background check reveals a record for
conviction of any of the following crimes or offenses. (If you are not sure which crimes are considered disqualifying offenses, please
see the attachment entitled “Disqualifying Crimes”.)
(1) In New Jersey, any crime or disorderly persons offense:
(a) involving danger to the person, meaning those crimes and disorderly persons offenses set forth in N.J.S.2C:11-1et seq.; N.J.S.2C:12-
1et seq., N.J.S.2C:13-1et seq., N.J.S.2C:14-1et seq., or N.J.S.2C:15-1et seq.; or
(b) against the family, children, or incompetents, meaning those crimes and disorderly persons offenses set forth in N.J.S.2C:24-1et
seq.; or
(c) involving theft as set forth in N.J.S.2C:20-1 et seq.; or
(d) involving any controlled dangerous substance or controlled substance analog as set forth in Chapter 35 of Title 2C of the
New Jersey Statutes except paragraph (4) of subsection a of N.J.S.2C:35-10.
(2) In any other state or jurisdiction, of conduct which, if committed in New Jersey, would constitute any of the crimes or
disorderly persons offenses described in paragraph (1) of this subsection.
15. Check only one box:
I have no record of conviction for any of the disqualifying crimes or offenses identied above.
I have been convicted of one or more of the disqualifying crimes or offenses identied above.
Every disqualifying conviction on record must be disclosed. True copies of each judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents
(including employer or supervisor letters of reference, if applicable) which present clear and convincing evidence
of rehabilitation must be submitted with this form. Failure to disclose a disqualifying conviction may result in
automatic termination of your current employment, denial of an initial or renewal application as a homemaker-
home health aide, revocation of certification or conditional certification and/or a fine of up to $1,000.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of
the county where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions for disqualifying crimes/offenses: You must notify the New Jersey Board
of Nursing within no more than ve (5) business days if you are convicted of any of the disqualifying crimes or offenses identied above
after this form has left your hands. Failure to do so may result in automatic termination of your current employment, denial of an
initial or renewal application for certication, revocation of your certication or conditional certication as a homemaker-home
health aide and/or a ne of up to $1,000.
- 5 -
- 6 -
16. 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 proivde 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/expired
17. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
18. Have you ever had a professional or occupational 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
19. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational 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
20. Have you ever been named as a defendant in any litigation related to any practice as a homemaker-home health aide, nurse or other
professional or occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
21. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a certication
board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
22. 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
23. 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 home health care, 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 17 through 23, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
You must immediately inform the New Jersey Board of Nursing in writing of any address change. Name
change requires the submission of legal documentation.
- 7 -
Afx Seal Here
}
ss.
AFFIDAVIT
Please identify any person other than the applicant who helped to prepare this form:
_________________________________ _____________ ___________________________________
Name (print) Date Signature
This afdavit is to be executed by the applicant before a notary public:
State of: _______________________________
County of: ______________________________
I, ___________________________________________ , in making this application to the New Jersey Board of Nursing for certication
or licensure under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the New Jersey Board of Nursing,
swear (or afrm) that I am the applicant and that all 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
certication or licensure or to withhold renewal of or suspend or revoke a certicate or license issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:11-23 et seq., together with the Rules and Regulations of the New Jersey Board
of Nursing, N.J.A.C. 13:37-14.1 through 13:37-14.17, and fully understand that in receiving certication or licensure from the Board, I
bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. 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.
________________________________________________
Signature of applicant
Sworn and subscribed to before me this ________________
day of ____________________________, _____________
Month Year
________________________________________________
Name of Notary Public (please print)
________________________________________________ __________________________________
Signature of Notary Public My Commossion Expires
Ofcial Use Only - Do Not Write Below The Line Candidate number____________________________
Certicate number ___________________________
Please paste a clear, 2” x 2”
passport-style photograph of
your head and shoulders here.
The background must be white,
your features clear cut, and
your face must be at least one-
inch long. Do not use staples or
tape to attach the photograph.
Sign your name directly on the front of the photograph.
Avoid covering the features of the photograph.
The photograph provided must be a recent one having
been taken no more than six months prior to the
submission of the application.
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CertifiCatiOn and authOrizatiOn fOrm
f
Or a Criminal histOry BaCkgrOund CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
MonthDayYear 
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
BoardorCommittee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
DualLicense
LicenseType1
________________________
Applicant’sNumber
________________________
LicenseType2
________________________
Applicant’sNumber
________________________
HHA
- 9 -
CertifiCation
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, 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certicationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicense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 qualications for certication or licensure. 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
Rev. 10/1/16
Disqualifying Crimes
Crimes Set Forth In N.J.S. 2C That Disqualify An Applicant
Pursuant To N.J.S. 45:11-24.3
(1) In New Jersey, any crime or disorderly persons offense:
(a) involving danger to the person, meaning those crimes and disorderly persons offenses set forth in N.J.S.
2C:11-1 et seq., N.J.S. 2C:12-1 et seq., N.J.S. 2C:13-1 et seq., or 2C:14-1 et seq., N.J.S. 2C:15-1 et
seq.; or
(b) against the family, children or incompetents, meaning those crimes and disorderly persons offenses
set forth in N.J.S. 2C:24-1 et seq.; or
(c) involving theft as set forth in chapter 20 of Title 2C of the New Jersey Statutes; or
(d) involving any controlled dangerous substance or controlled substance analog as set forth in chapter
35 of Title 2C of the New Jersey Statutes except paragraph (4) of subsection a of N.J.S. 2C:35-10.
(2) In any other state jurisdiction, of conduct which, if committed in New Jersey, would constitute
any of the
crimes or disorderly persons offenses described above in paragraph (1) of this section
.
N.J.S. 2C:11
N.J.S. 2C:11-1 Bodily Injury
N.J.S. 2C:11-2 Criminal Homicide
N.J.S. 2C:11-3 Murder
N.J.S. 2C:11-4 Manslaughter
N.J.S. 2C:11-5 Death by Auto or Vessel
N.J.S. 2C:11-6 Aiding Suicide
N.J.S. 2C:12
N.J.S. 2C:12-1 Assault
N.J.S. 2C:12-2 Recklessly Endangering Another Person
N.J.S. 2C:12-3 Terroristic Threats
N.J.S. 2C:12-10 Stalking
N.J.S. 2C:13
N.J.S. 2C:13-1 Kidnapping
N.J.S. 2C:13-2 Criminal Restraint
N.J.S. 2C:13-3 False Imprisonment
N.J.S. 2C:13-4 Interference With Custody
N.J.S. 2C:13-5 Criminal Coercion
N.J.S. 2C:13-6 Enticing Child Into Motor Vehicle,
Structure or Isolated Area
N.J.S. 2C:14
N.J.S. 2C:14-2 Sexual Assault
N.J.S. 2C:14-3 Criminal Sexual Contact
N.J.S. 2C:14-4 Lewdness
- 2 -
- 10 -
N.J.S. 2C:15
N.J.S. 2C:15-1 Robbery
N.J.S. 2C:15-2 Carjacking
N.J.S. 2C:20
N.J.S. 2C:20-2.1 Automobile Theft
N.J.S. 2C:20-3 Theft by Unlawful Taking or Disposition
N.J.S. 2C:20-4 Theft by Deception
N.J.S. 2C:20-5 Theft by Extortion
N.J.S. 2C:20-6 Theft of Property Lost, Mislaid or
Delivered by Mistake
N.J.S. 2C:20-7 Receiving Stolen Property
N.J.S. 2C:20-7.1 Fencing
N.J.S. 2C:20-8 Theft of Services
N.J.S. 2C:20-9 Theft by Failure to Make Required
Disposition of Property Received
N.J.S. 2C:20-10 Unlawful Taking of Means and Conveyance
N.J.S. 2C:20-11 Shoplifting
N.J.S. 2C:20-13 Library Materials, Purposeful Concealment, Prima Facie
Presumption
N.J.S. 2C:20-14 Taking Person into Custody for Probable Cause for Belief
of Willfully Concealing Library Material; Arrest without
Warrant; Probable Cause for Belief of Theft; Immunity
from Liability
N.J.S. 2C:20-15 Sign: Posting
N.J.S. 2C:20-16 Maintaining Facility for Sale of Stolen
Automobiles or their Parts
N.J.S. 2C:20-17 Employment of Juvenile to Commit Automobile Theft
N.J.S. 2C:20-18 Leader of Auto Theft Trafcking Network
N.J.S. 2C:20-25 Computer-Related Theft
N.J.S. 2C:20-26 Property or Services of $75,000 or More
N.J.S. 2C:20-27 Property or Services Between $500 and $75,000
N.J.S. 2C:20-28 Property or Services Between $200 and $500
N.J.S. 2C:20-29 Property or Services of $200 or less
N.J.S. 2C:20-30 Damage or Wrongful
Access to Computer System
N.J.S. 2C:20-31 Disclosure of Data from Wrongful
Access
N.J.S. 2C:20-32 Wrongful Access to Computer
N.J.S. 2C:20-33 Copy or Alteration of Program or Software with V
alue of
$1,000 or less
- 11 -
- 12 -
N.J.S. 2C:20-36 Prohibited Transactions Involving Food Stamps, Coupons,
or ATP Cards of $150 or More
N.J.S. 2C:20-37 Prohibited Transactions Involving Food Stamps, Coupons,
or
ATP Cards of Less than $150
N.J.S. 2C:24
N.J.S. 2C:24-1 Bigamy
N.J.S. 2C:24-4 Endangering Welfare of Children
N.J.S. 2C:24-5 Willful Non-Support
N.J.S. 2C:24-6 Unlawful Adoptions
N.J.S. 2C:24-7 Endangering the Welfare of an Incompetent Person
N.J.S. 2C:24-8 Endangering the Welfare of Elderly or Disabled
N.J.S. 2C:35
N.J.S. 2C:35-3 Leader of Narcotics Trafcking Network
N.J.S. 2C:35-4 Maintaining or Operating a Controlled Dangerous
Substance Production Facility
N.J.S. 2C:35-5 Manufacturing, Distributing or Dispensing
N.J.S. 2C:35-6 Employing a Juvenile in a Drug Distribution Scheme
N.J.S. 2C:35-7 Distributing, Dispensing or Processing Controlled
Dangerous Substance or Controlled Substance Analog on
or within 1,000 feet of School Property or Bus
N.J.S. 2C:35-8 Distribution to Persons under age 18
N.J.S. 2C:35-9 Strict Liability for Drug Induced Deaths
N.J.S. 2C:35-10 Possession, Use or Being Under the Inuence, or Failure
to Make Lawful Disposition (except paragraph (4) of
subsection 9).
N.J.S. 2C:35-11 Imitation Controlled Dangerous Substance; Distribution,
Possession, Manufacture, etc.
N.J.S.2C:35-13 Obtaining By Fraud
N.J.S.2C:35-16.1 Conviction of Drug Related Offenses Taking Place Upon
Leased Residential Premises
subsection 9).
N.J.S. 2C:35-11 Imitation Controlled Dangerous Substance; Distribution,
Possession, Manufacture, etc.
N.J.S.2C:35-13 Obtaining By Fraud
N.J.S.2C:35-16.1 Conviction of Drug Related Offenses Taking Place Upon
Leased Residential Premises
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/default.aspx
Certied Homemaker-Home Health Aide
and Certication Fee Schedule
Initial Application Fee (nonrefundable) .................................. $ 50.00
Certication Fee (Based on the date of application - Choose One Only)
September 3, 2017 thru November 30, 2018 ($ 30.00)........... $ _____
December 1, 2018 thru September 2, 2019 ($ 15.00)............. $ ______
Please remit the total by check or money order only........... $ ______
- 13 -
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Initial Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 10 May 2022

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