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

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Instructions for Reinstating/Reactivating a License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
124 Halsey Street, 6th Floor, P.O. Box 45040
Newark, New Jersey 07101
(973) 504-6582
Instructions for Reinstating/Reactivating a License
An individual whose license or registration is in an inactive or expired status may ll out this application to start
the reinstatement/reactivation process. However, if the Board, upon review of this application, determines that
additional information is required because it is necessary to evaluate your current competencies, you may be
required to submit to an examination and/or other requirements to be determined by the Board.
1. Submit:
a. A completed application for reinstatement/reactivation.
b. A signed and dated list that includes every job you held during the period that your New Jersey license
or certicate was not in an active status. The list must include each employer’s name, address and
telephone number. You also must indicate whether you were practicing your profession or occupation
during the period your license was suspended or expired, and whether that practice was compensated
or uncompensated.
c. Proof that you have completed continuing education courses for the immediately preceding renewal
period, as required by N.J.S.A. 45:2D-7 and N.J.A.C. 13:34C-5.1. Acceptable proof would include,
but is not 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 will be accepted by the Board.
d. A letter of verication of licensure, registration or certication from every state or jurisdiction where
you hold or have held a license, registration or certicate.
e. A completed Certication and Authorization form for a criminal history background check.
f. The appropriate fee. You may send a check or money order payable to the State of New Jersey. To
determine the appropriate amount, please see the fee schedules below. If your license is
currently in an “Inactive” or “Retired” status, you must pay only the current renewal fee. If your
license is currently in “Expired” status, and you desire an “Active” license, you must pay the
reinstatement fee plus the current renewal fee and, if your license expired prior to the current licensing
period, the immediate past renewal fee.
2. Mail to: Attn: Reinstatements
State Board of Marriage Family Therapy Examiners
Alcohol and Drug Counselor Committee
P.O. Box 45040
Newark, NJ 07101
Please note: Your application will not be processed until the Board has received this completed application
and all of the required documents noted above. Failure to submit all of the requested documentation will delay
the processing of your application. Please be advised that the Board may request that you submit additional
information in order to process your application.
Licensed Clinical Alcohol and Drug Counselor
(LCADC) Fee Schedule
Reinstatement Fee $ 125.00
Current Renewal Fee $ 250.00
Fingerprint Resubmit Fee $ 18.75
Continuing Education Courses - 40 Credit Hours (LCADC)
Certied Alcohol and Drug Counselor
(CADC) Fee Schedule
Reinstatement Fee $ 125.00
Current Renewal Fee $ 180.00
Fingerprint Resubmit Fee $ 18.75
Continuing Education Courses - 60 Credit Hours (CADC)
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
124 Halsey Street, 6th Floor, P.O. Box 45040
Newark, New Jersey 07101
(973) 504-6582
Application to Reinstate/Reactivate a License or Registration
Please check one: I am applying to have my license/certicate Reinstated Reactivated
N.J. License/Certicate No.:____________________________ Type of License/Certicate: _______________________________
Initial License/Certicate Date: __________________________ Year of last renewal: __________________
For reinstatements: a nonrefundable reinstatement fee, the current renewal fee, and the immediate past renewal fee. For
reactivations: a nonrefundable current renewal fee. The fee(s) must be submitted in the form of a check or money order
made out to the State of New Jersey and must be submitted with this application for reinstatement/reactivation. (Applicants
should understand that if the application ling 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
3. *Social Security No: ____ - ____ - ____
You must provide your Social Security number to the Board. Failure to do so will result in denial of licensure or registration
reinstatement/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 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; and
b. the Probation Division or any other agency responsible for child support enforcement, upon request.
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 reinstatement/reactivation of licensure or registration. 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 registration.
_________________________________ __________________________________________ ___________________
Applicant’s name (please print) Applicant’s signature Date
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signature
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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
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signature
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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
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.
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 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. _________________________________________________________________
Middle initial Last name First name
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
Date issued/expiredType of license or certicate Number State or jurisdiction that issued the license or certicate
_____________________ _______________________ ____________________________ ____________________
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 professional license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
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 alcohol and drug counseling or other
professional 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 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 group
related to the practice of alcohol and drug counseling 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,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
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
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
________________ ______________________ ____________________________ _____________________ ___________
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
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C r r C a CCertifi ation for einstatement/ ea tivation ppli ation
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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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Marriage and Family Therapy Examiners
Alcohol and Drug Counselor Committee
P.O. Box 45040
Newark, New Jersey 07101
(973) 504-6582
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 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.
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 ReinstatingReactivating a License (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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