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

Fill Online, Printable, Fillable, Blank Instructions for Reinstatement of a Lapsed 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 Reinstatement of a Lapsed License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 66 minutes to complete

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

  • 7 signatures
  • 56 check-boxes
  • 209 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 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
Instructions for Reinstatement of a Lapsed License
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
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
reinstatement application and materials may be downloaded from the Board of Nursing’s website and
include the following:
1. Reinstatement Application:
Complete the application, including the Certication and Authorization for a Criminal History
Background Check, attach a
clear, full-face passport photograph (2˝x 2˝) of your head and
shoulders, taken within the past six months, with your name printed on the back of
the photo 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:
a. Application Fees:
N.J.S.A. 45:1-7.4a.
(1) Payment of the renewal fee for the current biennial period.
(2) Payment of the unpaid renewal fee for the biennial period immediately preceding the current
renewal period.
(3) Payment of a reinstatement fee.
b. 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.
c. Proof of Competency:
(1) If applicable, satisfactory proof that you have maintained prociency by completing the
continuing education hours or credits required for the renewal of an active license
or certicate of registration or certication (N.J.A.C. 13:37-5.2(i) 2).
d. N.J.S.A. 45:1-7.4e.
(1) If a board review of an application for reinstatement or reactivation under this section
establishes a basis for concluding that there may be practice deciencies in need of
remediation prior to reinstatement or reactivation, the board may require the applicant to
submit to and successfully pass an examination or an assessment of skills, a refresher
course, or other requirements as determined by the board prior to reinstatement or reactivation
of the license.
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
N.J.A.C. 13:37-5.5 Fee Schedule
Licensure Reinstatement Fee
Original License Issued In An
Original License Issued In An
Odd Numbered Year Even Numbered Year
Type of Fee
License expired:
May 31, 2019
License expired:
May 31, 2020
License expired
prior to:
May 31, 2019
License expired
prior to:
May 31, 2020
Current biennial
renewal fee $120.00 $120.00 $120.00 $120.00
Previous biennial
renewal fee $120.00 $120.00
Reinstatement fee $100.00 $100.00 $100.00 $100.00
ATD Surcharge $ 5.00 $ 5.00 $ 5.00 $ 5.00
Total $345.00 $225.00 $345.00 $225.00
Expiration date information is available on the Board of Nursing’s website under online verication tab.
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 Reinstate a Lapsed License
This application must be completed and returned to the New Jersey Board of Nursing
ofce before a clinical practice letter is issued.
Along with the submission of this completed application, all fees must be paid in the form of a check or money order made
out to the State of New Jersey (review Licensure Reinstatement Fee page). The fee(s) must be submitted with this application for
reinstatement (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 reinstatement 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
Attach a clear, full-face pass-
port-style photograph (2˝x 2˝) of
your head 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
Expiration 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 reinstatement.
*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
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 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 certificates 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 Bureau of Citizenship and Immigration Services (B.C.I.S.).
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 B.C.I.S. 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) through d will result in a denial of
reinstatement 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 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
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violationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednot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,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseor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. Areyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardin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anyemployer,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abovequestions,numbers11through17,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
CertifiCation for reinstatement appliCation
I, ________________________________________________ , in making this application to the Board or Committee
for reinstatement 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 sufficient to deny reinstatement 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 qualifications for reinstatement. 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 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
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 Reinstatement of a Lapsed 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 State.)
1. _________________________________________________________________________
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)
Are you currently working as a nurse, or did you work as a nurse while your license was
lapsed or expired?
Yes
No
Provide an explanation: ______________________________________________________
(Sign and date reverse side)
Did you work as a nurse while your license was inactive?
Yes
No
Provide an explanation: ______________________________________________________
Were you terminated or asked to resign?
Yes
No
Provide an explanation: ______________________________________________________
2. _________________________________________________________________________
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)
Are you currently working as a nurse, or did you work as a nurse while your license was
inactive?
Yes
No
Provide an explanation: ______________________________________________________
Did you work as a nurse while your license was inactive?
Yes
No
Provide an explanation: ______________________________________________________
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 $62.70 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 $58.69 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: _________________________
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: ___________________________________________________________
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
________________________
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 toa thorough investigation of mypresent and past employment and other activities for the purpose
of verifying my qualications forcerticationor 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
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 Reinstatement of a Lapsed 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