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

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Instructions for Reinstatement (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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  • 27 check-boxes
  • 42 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Instructions for Reinstatement
In accordance with the Uniform Enforcement Act, a professional or occupational license or registration may be reinstated,
provided that the applicant otherwise qualies for licensure or registration and complies with the provisions of N.J.S.A. 45:
1-7.2a, b and c. The necessary application and materials for applying for reinstatement are enclosed.
1. Complete:
• The enclosed application for reinstatement.
2. Enclose:
• Payment of all past delinquent renewal fees and payment of a current renewal fee;*
• Payment of a reinstatement fee.
• An afdavit of employment listing each job held during the lapsed licensure or certication period. This afdavit of
employment must include the names, addresses and telephone numbers of each employer;
• A notarized statement indicating if you were engaged in the practice of your professionor occupation in New Jersey
during the period that your New Jersey license or certicate was lapsed. If you were practicing your profession or
occupation during this lapsed license period, you must include a description of the type of work or projects with which
you were involved; and
• The Criminal History Background Check lled out completely. See the enclosed instructions.
3. Submit to the:
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor
P.O. Box 183
Trenton, New Jersey 08625
Upon review and approval of your reinstatement application, a license will be issued.
* Please call the Committee’s ofce if you need to nd out about the total amount of fees you may owe to the Committee.
Revised 2/25/14
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Application for Reinstatement of an Athletic Trainer License
Date : ____________________________
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act
(OPRA).
Please print clearly. You must answer all of the questions on this application. The application must be notarized and accompanied
by the enclosures noted on the instruction sheet and the total fee noted on the enclosed invoice.
Personal Information Date of birth: _____________________
Month Day Year
Place of birth: ____________________
City State Country
Mr.
Name Mrs. __________________________________________________________ ( _____________________ )
Ms.
Last name First name Middle initial Maiden name
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
Type of License: __________________________________ N.J. License number: ____________________________
Initial License date: __________________________
Month Day Year
PA-94-1
Answer all of the questions below for the time period since you were last licensed in NewJersey.
1. Have you been arrested, charged or convicted of any crime or offense Yes No
that you have not already reported to your board/committee? (Minor
trafc offenses, such as speeding or parking need not be provided but
motor vehicle offenses such as driving while impaired or intoxicated
must be disclosed.)
2. Has any action been taken or is any action now pending against your Yes No
professional license or have you been permitted to surrender or otherwise
relinquish your license to avoid inquiry, investigation or action by any other
licensing authority that you have not already reported to your board/committee?
SEE THE ATTACHED INSTRUCTIONS BEFORE ANSWERING THE FOLLOWING QUESTIONS:
3. Are you currently engaged in the illegal use of controlled dangerous substances? Yes No
“Currently” is dened as “within the last two years.” Note: Individuals answering
“Yes” to this question will receive follow-up correspondence directly from the
Committee’s ofce. If you are asserting the Fifth Amendment privilege, check this box.
4. Do you have a medical condition or do you engage in the use of chemical Yes No
substances which in any way impairs or limits your ability to practice your
profession? Note: Individuals answering “Yes” to this question will receive
follow-up correspondence directly from the Committee’s ofce. If you are
asserting the Fifth Amendment privilege, check this box.
AFFIDAVIT OF APPLICANT
I,____________________________________________, being duly sworn, depose and say under penalty of
false statement, I am the person described and identied in this application; that the information given in this
application and all submitted materials contain no willful misrepresentations and that the information is true
and complete. I understand that should an investigation at any time discloseotherwise, my application may be
rejected, and I may face legal sanctions if I am already licensed. I understand that in signing this application for
reinstatement, I am consenting to any reasonable inquiry that may be necessary to verify the information I have
provided on this form or may provide in conjunction with this application.
_____________________________________________
Signature of applicant
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
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INSTRUCTIONS AND DEFINITIONS FOR
QUESTIONS THREE AND FOUR ON THE REINSTATEMENT APPLICATION
INSTRUCTIONS
Questions 3 and 4 pertain to the use of chemical substances and to medical conditions. Please read the denitions
carefully. Please be aware that you have the right to elect not to answer questions three and four 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 by checking the appropriate box
on the reinstatement application. Any claim of Fifth Amendment privilege must be made in good faith. If you
choose to assert the Fifth Amendment, you must check the appropriate box on the reinstatement application AND
submit a written explanation directly to the Committee at P.O. Box 183, Trenton, NJ 08625.
You must fully respond to all of the other questions on the application. Your application for licensure will be
processed even 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 which 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 pursuant to N.J.S.A 45:1-20.
DEFINITIONS
Questions 3 and 4 - Denition of terms:
“Medical Condition” includes any physiological, mental or psychological condition, including pedophilia,
exhibitionism or voyeurism, or any disorder such as, but not limited to, the diagnosis of orthopedic, visual, speech
and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
diabetes, mental retardation, emotional or mental illness, specic learning disabilities, HIV disease, tuberculosis,
drug addiction and/or alcoholism.
“Chemical substances” are to be construed to include alcohol, drugs or medications, including those taken
pursuant to a valid prescription 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 that the use of drugs may have an ongoing impact on one’s functioning
as a licensee, or within the last two (2) years.
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Athletic Training Advisory Committee
P.O. Box 46017
Newark, New Jersey 07101
(973) 504-6414
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
________________________
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 Reinstatement (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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