Fillable Instructions for Reactivation of an Inactive License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Instructions for Reactivation of an Inactive License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Instructions for Reactivation of an Inactive License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 63 minutes to complete

The Instructions for Reactivation of an Inactive License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 20 pages long and contains:

  • 5 signatures
  • 44 check-boxes
  • 213 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

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Jersey Office 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/nursing/
Instructions for Reactivation of an Inactive License
In accordance with the Uniform Enforcement Act, a professional or occupational license or certicate
of registration may be reactivated, provided that the applicant otherwise qualies for licensure,
registration or certication, and complies with the provisions of N.J.S.A. 45:1-7.2 a, b, c and d. The
necessary licensure reactivation application and materials may be downloaded from the Board of Nursing’s
website and include the following:
1. Reactivation Application:
Complete the application, including the Certication and Authorization for a Criminal History
Background Check, attach a current passport photograph to the application
and submit the application
and the required fee(s)
to:
New Jersey Board of Nursing
P.O. Box 45010
Newark, NJ 07101
2. Application Packet:
Application Fees:
(1) Payment of the current biennial license renewal fee (effective March 2006 - $120.00)
(N.J.A.C. 13:37-5.5 (a)6i); and
(2) Effective July 1, 2008, a $ 5.00 surcharge fee for the alternative-to-discipline program
(N.J.A.C. 13:37-5.5 (a)12) for those reactivating.
Certication of Employment:
(1) Submit a signed and dated Certication of Employment that clearly indicates whether you
were engaged in your profession during the period that your
license has been inactive. In
addition, the Certication of Employment must include the name, address and telephone
number of every employer by whom you were employed. If
you were practicing your
profession during the period of inactivity, you must describe in detail the type of work or
projects with which you were involved.
Proof of Competency:
(1) A person seeking reactivation more than ve years after the expiration date of
a license shall meet all of the requirements for reactivation.
The licensee
shall fulll all of the eligibility requirements found at N.J.A.C. 13:37-2.1 (N.J.A.C. 13:37-5.2(j)).
Every licensee shall pass either the National Council Licensure Examination
for
Registered Nurses (NCLEX-RN) or the National Council Licensure Examination for Practical
Nurses (NCLEX-PN). Please contact the New Jersey Board of Nursing’
s reactivation
staff member Sameerah Bond at (973) 273-8030 for support with this process.
(2) Provide evidence of successful completion of a refresher course consisting of 30 hours of
didactic and clinical education (N.J.A.C. 13:37-5.2 (j)2) conducted by a
qualied instructor
( N.J.A.C. 13:37-1.7).
New Jersey Office 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/nursing/
Reactivation Fees
Inactive to Inactive-Paid $65.00
Inactive-Paid to Active $60.00
Inactive to Active $125.00
Expired to Inactive-Paid $160.00
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/nursing
Application to Reactivate an Inactive License
You may not practice in the State of New Jersey until your license or certicate has been reactivated.
N.J.LicenseNo.:______________________________________TypeofLicense:_______________________________________
InitialLicenseDate:________________________________DateLicenseBecameInactive:_____________________________
PleasesubmitwiththisapplicationacheckormoneyordermadepayabletotheStateofNewJersey,forthecorrectamount
toreactivateyourlicense(reviewReactivationFeespage).(Applicantsshouldunderstandthatifthefeeispaidwithapersonal
check,andthecheckisreturnedbythebankduetoinsufcientfunds,thenextstepinthereactivationprocesswillbedelayed
untilthefeeispaid.)
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants,without their
consent.However,youarerequiredtoprovideanaddressthatmaybereleasedtothepublicinourdirectoriesorinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed.Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
Informationthatyouprovideon thisapplication(includingyouraddressof record)maybesubjectto publicdisclosureas
requiredbytheOpenPublicRecordsAct(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:________________________
MonthDayYear
1. Name_________________________________________________________________________________________________
Lastname Firstname Middleinitial Maidenname
2. Address
Home: _____________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
_____________________________________ ___________________________________
Telephonenumber(includeareacode) E-mailaddress
 Business: ___________________________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
____________________________________________________________________________________________
Street City State ZIPcode County
 Mailing:____________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
Attacha clear, full-face pass-
port-stylephotograph(2˝x2˝)of
yourheadandshoulders,taken
withinthepastsixmonths,with
yournameprintedontheback
ofthephoto.
Aphotoisrequiredwitheach
application.
Do not use staples to attach
thephoto
Ofce Use Only
Inactivedate:
__________________________
Status:
__________________________
Licensenumber:
__________________________
Applicantnumber:
__________________________
Effectivedate:
__________________________
3. *SocialSecurityNo:____-____-____
YoumustprovideyourSocialSecuritynumbertotheBoard.Failuretodosowillresultindenialoflicensurereactivation.
*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Committee
isrequiredtoobtainyourSocialSecuritynumber. Pursuanttotheseauthorities,theBoardisalsoobligatedtoprovide
yourSocialSecuritynumberto:

a. the Director ofTaxation 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 renewalof professionalor occupational licenses or certicates to U.S.citizens or
qualified 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yourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbe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questionsa(1)throughdwillresultinadenialofreactivation
oflicensure.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,
immediaterevocationorsuspensionoflicensure.
______________________________________________________________________________________________

Applicant’sname(pleaseprint)Applicant’ssignatureDate
click to sign
signature
click to edit
6. IllegalUseofControlledDangerousSubstances
Thequestionbelowpertainstotheillegaluseofcontrolleddangerous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thisquestion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application.Yourapplicationfor licensure orcertication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ontheFifth
Amendment,providedthattheAttorneyGeneralrstgrantsyouimmunityaffordedbystatutorylaw,(N.J.S.A.45:1-20).
“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365days,whicheverislonger.
“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. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdenedas
“recentlyenough…[to]haveanongoingimpact…”or“withintheprevious365days,”whicheverislonger.)
 Yes No
Ifyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogram
thatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?
 Yes No
_____________________________________________________ ___________________________________
Applicant’ssignature Date
click to sign
signature
click to edit
7. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
8. Haveyoueverbeensummoned;arrested;takenintocustody;indicted;tried;chargedwith;admittedintopre-trialintervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.)
Yes No
9. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaof
guilty,nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.   Yes No
If“Yes,”provideacopyofthejudgmentofconvictionandthereleasefromparoleorprobation.Pleaseprovideacomplete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
10. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykind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)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseprovidethatname._________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expire
11. HaveyoueverbeendisciplinedordeniedanursinglicenseorcerticateofanykindinNewJersey,anyotherstate,theDistrict
ofColumbiaorinanyotherjurisdiction?  Yes No
12. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
13. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyany
agencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
 Yes No
14. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofnursingorotherprofessionalpractice
inNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
15. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
16. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction?  Yes No
17. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
related to the practice of nursing or other professional practice in New Jersey, any other state, the
DistrictofColumbiaorinanyotherjurisdiction?  Yes No
Iftheanswertoanyoftheabovequestions,numbers11through17,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
CertifiCation for reaCtivation appliCation
I, ________________________________________________ , in making this application to the Board for reactivation
of 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 sufficient to deny reactivation or to withhold renewal of or suspend or revoke a license issued by the Board.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for reactivation. I further authorize all institutions, employers, agencies and all governmental
agencies and instrumentalities (local, state, federal or foreign) to release any information, files 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 Office 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/nursing/
Employment Certication for the Reactivation of an Inactive License
Directions: Please complete this certication, sign and date it and return it to the New Jersey
Board of Nursing. If you have had more than two employers, please add additional sheets of paper
with the employment data. The Board may contact your employer(s) to verify your employment.
____________________________________________________________________________
First name Middle name Last name Maiden name
____________________________________________________________________________
Present Street Address City State ZIP Code
R.N. License No. ___________________________
L.P.N. License No. ___________________________
A.P.N. Certicate No. _________________________
Employment Data: (For the past ve (5) years in New Jersey or in any other jurisdiction.)
1(a)_________________________________________________________________________
Name of employing agency or facility
_________________________________________________________________________
Street address
_________________________________________________________________________
City State ZIP Code
_________________________________________________________________________
Job Title Employment Dates: From To
_________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
1(b) Are you currently working as a nurse or did you work as a nurse while your license was
inactive?
Yes
No
Provide an explanation: ______________________________________________________
(Sign and date reverse side)
1(c) Were you terminated or asked to resign?
Yes
No
Provide an explanation: ______________________________________________________
2(a)_________________________________________________________________________
Name of employing agency or facility
_________________________________________________________________________
Street address
_________________________________________________________________________
City State ZIP Code
_________________________________________________________________________
Job Title Employment Dates: From To
_________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
2(b) Are you currently working as a nurse, or did you work as a nurse while your license was
inactive?
Yes
No
Provide an explanation: ______________________________________________________
2(c) Were you terminated or asked to resign?
Yes
No
Provide an explanation: ______________________________________________________
_________________________________ ________________________________ ______________________
Applicant’s name (Please print) Applicant’s signature Date
click to sign
signature
click to edit
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/nursing/
Dear Applicant:
In November 2003, legislation was passed that requires the Division of Consumer Affairs to conduct criminal
history record background checks on all health care professionals prior to the issuance of an initial license or
other authorization to practice a health care profession (N.J.S.A. 45: 1-28 et seq.). The records of the Division
show that you are a current applicant for licensure or certication as a health care professional, and as such,
the Division must arrange to conduct a criminal history check of your background.
In order for the Division to conduct a criminal history record background check, you must complete the
enclosed Certication and Authorization form and return it to the mailing address above.
(In-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward your information
about how to schedule an appointment with MorphoTrust, Inc., to have your ngerprints electronically
recorded. A $.0 ngerprinting fee must be paid to MorphoTrust, at the time of ngerprinting. The
$62.70 payment should be in the form of a check or money order made payable to MorphoTrust.
(Out-of-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward you one state
and one federal ngerprint card. Out-of-state applicants must have their ngerprints recorded, on the cards
provided, by their local police department, by their state police department or by their local law enforcement
agency. You must return the ngerprint cards to the Board or Committee with the required fee. Applicants
submitting ngerprint cards will be required to pay a $58.69 fee to have their ngerprints scanned into the
electronic system by MorphoTrust. The $. should be in the form of a check or money order made
payable to MorphoTrust.
If you fail to complete and return the Certication and Authorization form, your application for licensure or
certication will not be processed and your application will be considered abandoned.
The New Jersey Board of Nursing
New Jersey Board of Nursing
Licensure Reinstatement
Request for Nurse Refresher Course: Clinical Practice Letter
Purpose:
This request form is for a New Jersey nurse who is reinstating a lapsed nursing license to
obtain permission to complete the clinical component of a Nurse Refresher Course for licensure
reinstatement.
Directions: Please complete this request form and return it to:
New Jersey Board of Nursing
P.O. Box 45010
Newark, N.J. 07101
Attn: Sameerah Bond
Name of Applicant: ________________________ New Jersey License Number: ___________
Date of Initial Licensure: ____________________ Date of Licensure Expiration: ____________
Name of Nurse Refresher Course Institution: ________________________________________
City:__________________________________State: _______________ ZIP Code: _________
Course Dates: _________________________ Clinical Practice Dates: ___________________
Name of Agency for Clinical Practice: ______________________________________________
City:__________________________________State: _______________ ZIP Code: _________
Signature of Licensee: _____________________________________ Date: _______________
Signature of Nurse Refresher
Course Instructor: _________________________________________ Date: _______________
Continuing Education Compliance Report Form
Name: ______________________________________________________ R.N. License Number: _________________________
(Please print clearly)
L.P.N. License Number: ________________________
I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the
foregoing statements made by me are willfully false, I am subject to punishment, including but not limited to suspension or
revocation of a license and/or certication under N.J.S.A. 45:1-21.
Signature:_________________________________________________________ Date: __________________________________
New Jersey Office 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
Title of Program
Attach copies of the certicates*
Date
Program Provider
Contact
Hours
A total of 30 contact hours is required.
Total
_______
*Attach a copy of the program certicate of completion/attendance (usually one page) for each listing noted
above to add up to 30 contact hours. Please refer to N.J.A.C. 13:37-5.3 for information regarding approved C.E.U.
providers. Please note: The required 30 C.E.U.’s must be related to nursing. (www.NJConsumerAffairs.gov)
New Jersey Office 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
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 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.
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
________________________
Reactivation
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 andpast employment and other activities for the purpose
of verifying my qualications for certicationor licensure. I further authorize allinstitutions, 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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Instructions for Reactivation of an Inactive License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document