Fillable Instructions for Application for a Temporary Permit to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Instructions for Application for a Temporary Permit to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Instructions for Application for a
Temporary Permit to Practice as an Ophthalmic Dispenser
(For out-of-state applicants only seeking a temporary license in New Jersey)
1. You must attach a copy of your current out of state license.
2. You must request a verification of license from the state in which you are licensed.
3. You must attach a copy of your A.A.S. degree in Ophthalmic Science. If you did not
obtain a degree but completed credits in ophthalmic science, you may submit your
transcripts for Board review.
4. You will be required to sit for the next scheduled examination.
5. You must request for an exam application in writing, it can be faxed to
973-648-3355.
6. You must secure employment in New Jersey in order to be eligible for a Temporary
License. (Please be advised you do not have to work in New Jersey to sit for the New
Jersey State Licensing Examination.)
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Examiners of
Ophthalmic Dispensers and Ophthalmic Technicians
124 Halsey Street, 6th Floor, P.O. Box 45011
Newark, New Jersey 07101
(973) 504-6435
Application for a Temporary Permit to Practice as an Ophthalmic Dispenser
(For out-of-state applicants only)
Date: _____________________________
A nonrefundable application ling fee of $100 in the form of a check or money order made out to the State of New Jersey, must
be submitted with this application for a permit. (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 process that must be
followed to obtain a permit will be delayed until the fee is paid.) An additional fee of $210 must be sent to cover the
cost of temporary registration as an Ophthalmic Dispenser. This fee is refundable if you are deemed to be ineligible for
licensure or registration.
T
he Di
vision is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
conse
nt. 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 rec
ord, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your p
lace 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 Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
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.
A photograph is required with
each application.
Do not use staples to attach the
photograph.
Instructions for Application for a
Temporary Permit to Practice as an Ophthalmic Dispenser
(For out-of-state applicants only seeking a temporary license in New Jersey)
1. You must attach a copy of your current out of state license.
2. You must request a verification of license from the state in which you are licensed.
3. You must attach a copy of your A.A.S. degree in Ophthalmic Science. If you did not
obtain a degree but completed credits in ophthalmic science, you may submit your
transcripts for Board review.
4. You will be required to sit for the next scheduled examination.
5. You must request for an exam application in writing, it can be faxed to
973-648-3355.
6. You must secure employment in New Jersey in order to be eligible for a Temporary
License. (Please be advised you do not have to work in New Jersey to sit for the New
Jersey State Licensing Examination.)
3. 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.
4. 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.
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 payment of the loan. You will not be able to obtain a license or permit unless you provide the
required documents concerning the plan for payment 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 any of the questions a(1) through d will result in a denial of
licensure or registration. 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 registration.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
7. 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 or registration 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.)
For the purposes of these questions, the following phrases or words have the following meanings:
“Ability to practice as a temporarily registered ophthalmic dispenser” is to be construed to include all of the
following:
a. The cognitive capacity to exercise reasonable ophthalmic care judgments and to learn and keep abreast of professional
developments; and
b. The ability to communicate those judgments and related information to customers 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 temporarily registered ophthalmic dispenser, 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 treat-
ment (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 as-
sistance 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 as-
sessment 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 permit should be issued, whether conditions should be imposed or whether you are not eligible
for licensure or registration.
____________________________________________________ ___________________________________
Applicant’s signature Date
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, certicate or permit 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, certicate or permit 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, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
11. Have you ever been disciplined or denied a professional license, certicate or permit 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, certicate or permit 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 any prior practice as an ophthalmic dispenser, 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, certicate or permit 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 any prior practice as an ophthalmic dispenser, 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.
Education
1. What is the name and address of the high school you attended? _____________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. What years did you attend high school? _____________________
3. Did you graduate from high school? Yes No
If “Yes,” what was the date of your graduation? _______________________
(Please attach a copy of your diploma to this application.)
Month Year
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date certicate was issued
4. What is the name and address of the colleges or universities you have attended?
Name of college or university
Street address City State ZIP code
Name of college or university
Street address City State ZIP code
5. List all of the degrees that you have received from recognized colleges or universities. Please have each college or university forward
to the Board the ofcial transcript for each degree that you have earned.
Educational institution Inclusive years Degree, Major Date granted
Diploma or
Certicate
___________________________ _______________ ____________ ___________ _______________________
___________________________ _______________ ____________ ___________ _______________________
6. Did you receive an Associate of Applied Science degree in ophthalmic science? Yes No
7. Did you complete a 30-credit program? Yes No
If “Yes,” please indicate below those optical courses that you have completed or are currently attending.
______ Materials I _______Materials Lab I ______ Dispensing I ______ Dispensing Lab I
______ Materials II _______Materials Lab II ______ Dispensing II ______ Dispensing Lab II
______ Anatomy and Physiology of the Eye ______ Theory (Principles of Optics)
______ Contact Lens Theory
Experience
1. Please document that you have completed at least three years of work in the optical eld within the last seven years. Begin with your
current or most recent experience in the optical eld and then provide the relevant information concerning any other work experience
as you work back in time, chronologically.
(a) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
(b) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
(c) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
Instructions to the employer and applicant
The applicant must le this application with the State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians prior
to the time he or she begins work as a temporary Ophthalmic Dispenser.
This registration does not permit or empower any holder of a temporary permit to represent to the public that he or she is an
Ophthalmic Dispenser or Ophthalmic Technician duly licensed by the State Board of Examiners of Ophthalmic Dispensers and
Ophthalmic Technicians via examination.
Each applicant must enclose the prescribed fee in the form of a check or money order. The check or money order should be made
payable to the State of New Jersey.
Statement of the employer
Name of establishment: ________________________________________________________________________________________
Ofce address: ______________________________________________________________________________________________
Street address City State ZIP code
Telephone number:___________________________________ License number of licensee in charge: _________________________
(include area code)
Does the establishment have the minimum equipment stipulated in N.J.A.C. 13:33-3.5? (See the preceding page for instructions.)
Yes No
Full name of applicant: ________________________________________________________________________________________
Names of employees currently employed under permits at this address:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Afdavitoftheemployer
State of: __________________________________________________
County of: ________________________________________________
I, ______________________________________________________________ , being duly sworn, depose and say that I desire to
(Employer’s name-please print)
register __________________________________________________________ under a Temporary Ophthalmic Technician Permit
(Applicant’s name-please print)
that I believe the applicant to be of good moral character and that the above answers and statements are true and correct.
__________________________________________________
Employer’s signature
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
AfxSealHere
} ss.
Afdavitoftheapplicant
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 State Board of Examiners of
Ophthalmic Dispensers and Ophthalmic Technicians for licensure or registration under the provisions of Title 45 of the
General Statutes of New Jersey and the Rules of the State Board of Examiners of Ophthalmic Dispensers and Ophthalmic
Technicians, 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 licensure or registration or to withhold renewal of or suspend or revoke a license or permit
issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 52:17B-41.1 et seq., together with the Rules and Regulations of the
State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians, N.J.A.C. 13:33-1.1 et seq., and fully
understand that in receiving a license or permit 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 licensure or registration. 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.
_____________________________________________
Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
AfxSealHere
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
Forofceuseonly
Received: _______________________________________ Paid: _______________________________
Approved: ____________ Rejected: __________________ Date: _______________________________
Reason: _____________________________________________________________________________
_________________________________________________
_________________________________________________
Certied mailed: ______________________________________________________________________
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Examiners of Ophthalmic Dispensers
and Ophthalmic Technicians
P.O. Box 45011
Newark, New Jersey 07101
(973) 504-6435
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
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certicationbyanyother Board or Committee of the New Jersey Division of Consumer Affairs(abackgroundcheck
conductedfortheDepartmentofEducation,anotherstateagencyoranotherstatedoesnotapply)youwillnotberequiredto
bengerprintedasecondtime.However,theDivisionmustperformacriminalhistorybackgroundcheckeachtimeyouapply
forlicensureorcertication.The fee for this service is $18.75. Paymentshouldbemadeintheformofacheckormoney
orderpayabletotheStateofNewJerseyandshouldaccompanyyourapplicationpacket.
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evidenceof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.
Continuationonthereverseside➨
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
________________________
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.1/2/19
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Instructions for Application for a Temporary Permit to (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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