Fillable Instructions for Initial Cemetery Salespersons License New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Instructions for Initial Cemetery Salespersons License New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Instructions for Initial Cemetery Salespersons License New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 9 pages long and contains:

  • 4 signatures
  • 60 check-boxes
  • 112 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
Instructions for Initial Cemetery Salesperson’s License
EachapplicantforaninitialCemeterySalesperson’sLicensemustsubmitthefollowing:
1. Application Form
Thisapplicationmustbecompleted entirelyandsignedbytheapplicant.
2. Face Photo
Theapplicantmustsubmitatwoinchbytwoinch(2”x2”)facephotograph,ingoodcondition,andtakenwithin
thelastyear.
3. Criminal History
Thissectionoftheapplicationmustbecompleted entirelyiftheapplicanthasbeenarrestedforacriminaloffense
andsignedbytheapplicant.
4. A nonrefundable Application Filing Fee of $35.00 and $5.00 Temporary License Fee
Acheckormoneyordermadepayabletothe“StateofNewJersey”intheamountof$40.00($35.00anonrefundable
ApplicationFilingFeeand$5.00TemporaryLicenseFee).
5. Certication
Thisformmustbecompletedinitsentirelybyallapplicants.
6. Certication and Authorization Form
Thisformmustbecompletedinitsentirelybyallapplicants.
7. Designation of Agent
ThisformmustbecompletedonlyiftheapplicantresidesoutsideNewJersey.
Allformsmustbecompletelylledout.Anapplicationisnotcompleteuntilalloftherequiredmaterials,information
andremittanceshavebeenreceived.
Uponreceiptofacompletedapplication,theBoardwillissueatemporarylicenseforaperiodof60days(unlessthere
areclearreasonsfornotissuingatemporarylicense).Iftheapplicantisfoundtobequalieduponconclusionofthe
Board’sreviewof the application and investigation, the licensewill be sent to the cemetery andthe cemetery will
forwardittothelicensee.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
Application for a Cemetery Salesperson’s License
Print or type all information.
Date:_______________________________
A nonrefundable application ling fee of $35.00 (and a $5.00 temporary license fee), in the form of a check or money
ordermadepayabletotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatifthe
feesarepaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufcientfunds,thenextstepinthelicensure
orcerticationprocesswillbedelayeduntilthefeesarepaid.)
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
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).

 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
 Cemetery: ______________________________________________________________________________________
Nameofcemetery 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 photo is required with each
application.
Donotusestaples toattach the
photo.
3. SocialSecurityNumber
You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)Aof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;and
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest.
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. 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) Applicant’ssignature Date
click to sign
signature
click to edit
6. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
7. 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
8. 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.)
9. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofkindinNewJersey,anyotherstate,the
DistrictofColumbiaorinanyotherjurisdiction Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseprovidethatname.____________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
10. Haveyoueverbeendisciplinedordenied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
11. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
12. Has any action (including the assessment of fines 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orinanyotherjurisdiction? 
  Yes No
13. Haveyouever been named as adefendant in any litigation related to practiceas a cemetery salesperson orother professional
practiceinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?   Yes No
14. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
15. 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
16. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
relatedtopracticeasacemeterysalesperson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10through16,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.

Kindlyindicatetheappropriateresponsestoeachquestionsbelow.Intheeventtheresponsetoanyquestionsis“Yes”,pleaseexplain
belowindetailyourpositionanddutiesandwhetherthesedutiesarefullorpart-time.
1. Listcementeriesand/oragentswithwhichafliatedduringthelastveyears(ifany):
Name Address  Date
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Haveyoubeenemployedincementerysalesforveyearsormore? Yes No
If“Yes,”pleasesubmitdetails:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Areyoucurrentlyengaged,directlyorindirectly,intheconductofanyfuneralhomeorinthebusinessorprofessionofmortuary
science? Yes No
4. Areyouemployedasanofcer,superintendent,managerorclerkofacementerycompany? Yes No
Ifyouanswered“Yes”tothisquestionandquestion3,pleaseexplainhere:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CertifiCation
I, ________________________________________________ , in making this application to the New Jersey Cemetery Board
forlicensure,certifythatIamtheapplicant,thatalloftheinformationIhaveprovidedistrueandthatIwillengageduringactive
licensureasacemeterysalespersoninanyactivityprohibitedbyN.J.S.A.45:27-16c,whichincludes,indirectlyordirectly:
i. Themanufactureorsaleofmemorials;
ii. Themanufactureorsaleofprivatemansoleums;
iii. Themanufactureorsaleofvaults,includingvaultsinstalledinagravebeforeoraftersaleandincludingvaultsjoinedwitheach
otherintheground;and
iv. Theconductofanyfuneralhomeorthebusinessorprofessionofmortuaryscience.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose of
verifying my qualifications for 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.
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
click to sign
signature
click to edit
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
CertifiCation and authorization form
f
or a Criminal history BaCkground CheCk
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
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
Atruecopyofeverypolicereport,judgmentofconviction,sentencing
orderandterminationofprobationorder,ifapplicable,besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationbesubmitted
withthisform.
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.
:You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
________________________

Resubmit
________________________

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.9/18/09
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553

  That the undersigned do(es) hereby constitute and appoint the
NewJerseyCemeteryBoard,anditssuccessorsinofce,trueandlawfulagentandattorneyinthisStateuponwhom
alloriginalprocessinanyactionorlegalproceeding,pertainingtoP.L.1971,Chapter333,againsttheundersigned
maybeserved;andprovidedfurther,theundersigneddo(es)herebyirrevocablyconsentthatsuitsandactionsmay
becommencedagainsttheundersignedinthecourtsofthisStatebytheserviceofprocessoranypleadinguponthe
Board,intheusualmannerprovidedforserviceofprocessandpleadingbythestatutesandCourtRulesofthisState.
Suchserviceshallbevalidandbindingasifservicehadbeenmadepersonallyupontheundersigned.
theundersignedhasplacedhishandandsealthis_________________dayof
________________________________,20______.
_______________________________________________
Printnameoflicensee 
_______________________________________________
Signatureoflicensee
_______________________________________________
Addressoflicensee
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Instructions for Initial Cemetery Salespersons License New Jersey (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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