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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  • 13 check-boxes
  • 212 other fields

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Electrologists Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
Instructions for Reinstatement
In accordance with the Uniform Enforcement Act, a professional or occupational license or certicate of registration may
be reinstated, provided that the applicant otherwise qualies for licensure, registration, certication and complies with the
provisions of N.J.S.A. 45:1-7.4. The necessary application and materials for applying for reinstatement are enclosed.
Please Note: An individual that has been expired for 5 or more years must contact the Committee for reinstatement
instructions.
1. Submit:
a. A completed application for reinstatement.
b. The employment history that includes every job you held during the period that your New Jersey license or
certicate was not in active status. The list must include each employer’s name, address and telephone number.
You must also indicate whether you were practicing your profession or occupation during the period your
license was suspended.
c. Proof that you have completed continuing education courses for the immediately preceding renewal period.
Acceptable proof would include, but is not to be limited to, a copy of your course completion certicates. If you
were licensed to practice and are in good standing in another state, proof of completion of that state’s continuing
education requirement may be accepted by the Board
d. If you have held a license in another state during this period of suspension, you are also required to submit a
certication of licensure in good standing from all states in which you are or have been licensed to practice
electrology.
e. A completed Certication and Authorization form for a criminal history background check.
2. Enclose:
Expiration date Fees Total fee required
Reinstatement fee: $ 150.00
Renewal fee: $ 200.00
Criminal History Background: $ 18.75
Reinstatement fee: $ 150.00
Renewal fee: $ 400.00
Criminal History Background: $ 18.75
3. Mail to: State Board of Medical Examiners
Electrologists Advisory Committee
P. O. Box 45041
Newark, NJ 07101
Upon review and approval of your reinstatement application and approved criminal history results, a license or certicate
will be issued.
October 31, 2019
October 31, 2017
(Renewal periods prior to 2015)
$ 368.75
$ 568.75
- 1 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Electrologists Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
Application to Reinstate a License as an Electrologist
You may not practice in the State of New Jersey until your license or certicate is reinstated.
N.J. License/Certicate No.:____________________________ Type of License/Certicate: _______________________________
Initial License/Certicate Date: __________________________ Year of last renewal: __________________
A nonrefundable reinstatement fee (see instructions page) in the form of a check or money order made out 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 reinstatement process will be delayed until the fees
are paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public
Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: ________________________
Month Day Year
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 pass-
port-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.
- 2 -
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. Child Support (You must answer a, b, c and d.)
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.
- 3 -
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 you currently engaged in 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 you answered “Yes,” are you currently participating in a supervised rehabilitation 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
- 4 -
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 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 finding 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 or occupational license or certicate of any kind in New Jersey, any
other state, the District of Columbia or in any other jurisdiction? Yes No
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
11. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational
practice by any agency or certication board in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
14. Have you ever been named as a defendant in any litigation related to the practice of electrology or other professional or
occupational 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 or occupational 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
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 or
occupational group related to the practice of electrology or other professional or occupational 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.
- 5 -
Continuing Education
Please list all of the courses that you have successfully completed since your license expired or became inactive.
Date Title Subject Matter Sponsor No. of Hours
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
- 6 -
Employment since your license expired (You may photocopy this page if necessary.)
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
____________________________________________________________________________________________________________
City State ZIP code
Immediate supervisor’s name: __________________________________________________________________________________
Employer’s telephone number:_______________________________ Hours per week: ___________________________________
(Include area code)
Your major responsibilities (use additional sheets of paper if necessary): ______________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
Dates employed: from: __________________________ to: __________________________
month day year month day year
_________________________________________ ________________________________________ ______________________
Applicant’s name (Please print) Applicant’s signature Date
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signature
click to edit
- 7 -
CertifiCation for reinstatement/reaCtivation appliCation
I, ________________________________________________ , in making this application to the Board or Committee for
reinstatement /reactivation of my license or registration, 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 reinstatement/reactivation or to
withhold renewal of or suspend or revoke a license or registration 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 reinstatement/reactivation. 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
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signature
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- 8 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Electrologists Advisory Committee
P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
CertifiCation and authorization form
for 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lettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust 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
________________________
- 9 -
CertifiCation
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
applicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefull
disclosuresmaybedeemedsufcienttodenycerticationorlicensureortowithholdrenewaloforsuspendorrevokeacerticate
orlicenseissuedbytheBoardorCommittee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorizeall 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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