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
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
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.
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. 45:6-10.1 and N.J.A.C. 13:30-5.1. 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 or certication from every state or jurisdiction where you hold or
have held a license or certicate.
e. A completed Certication and Authorization form for a criminal history background check with the
appropriate fee (please see the attached form for the current fee).
f. 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 reinstatement fee and the current 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
New Jersey State Board of Dentistry
P.O. Box 45005
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.
Dentist Fee Schedule
Reinstatement Fee $ 200.00
2017-2019 Current Renewal Fee $ 390.00
If expired prior to 2017,
also pay the past renewal fee of: $ 390.00
Dental Assistant
Fee Schedule
Reinstatement Fee $ 100.00
2017-2018 Current Licensing Fee $ 90.00
If expired prior to 2016,
also pay the past renewal fee of: $ 50.00
Dental Hygienist Fee Schedule
Reinstatement Fee $ 100.00
2018-2019 Current Renewal Fee $ 120.00
If expired prior to 2017,
also pay the past renewal fee of: $ 120.00
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
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: __________________
A nonrefundable reinstatement fee, along with all past delinquent renewal fees, in the form of a check or money order made out
to the State of New Jersey, must be submitted with this application for reinstatement (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 insu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Number
IfyouwereissuedaSocialSecurityNumberoranIndividualTaxpayerIdenticationNumber,youmustprovideittothe
BoardorCommittee.Failuretodosomayresultindenialoflicensure/certication/reinstatement/reactivation.
*SocialSecurityNumber: __________-__________-__________
*IndividualTaxpayerIdentication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
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thisinformation.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovidethis
informationto:
(For healthcare-related boards, the following a, b and c entries apply. For boards not related to healthcare, only the a and
b entries apply.)
 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anAmericancitizen,pleaseenclosea copyofyourbirthcerticateorU.S.passport. 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yourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued
yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. 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matchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthe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throughdmayresultin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.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
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signature
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7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the definitions carefully.
Your responses will be treated confidentially and retained separately. Please be aware that you have the right to elect not to
answer those portions of the following questions which inquire as to the illegal use of controlled dangerous substances or
activity 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 applica
tion. Your application for licensure or certification 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 of the Fifth Amendment, provided that
the Attorney General first grants you immunity afforded by statutory law. (N.J.S.A. 45:1-20.)
For the purposes of these questions, the following phrases or words have the following meanings:
“Ability to practice your profession” is to be construed to include all of the following:
a. The cognitive capacity to exercise reasonable professional judgments, and to learn and keep abreast of professional
developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or
without the use of aids or devices, such as voice amplifiers; and
c. The physical capability to perform the duties of your profession, with or without the use of aids or devices,
such as corrective lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to
orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis,
cancer, heart disease, dia
betes, mental retardation, emotional or mental illness, specific learning disabilities, H.I.V. disease,
tuberculosis, drug addiction and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription 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 so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the
previous two years.
“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.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with
reasonable skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of
practice, the setting or manner in which you have chosen to practice?
Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable
skill and safety? Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is defined as
“within the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled
dangerous substances?
Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to
determine whether an unrestricted license or registration should be issued, whether conditions should be imposed or
whether you are not eligible for reinstatement/reactivation of licensure or registration.
____________________________________________________ ___________________________________
Signature of applicant Date
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signature
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8. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certificate, divorce decree or court order.
9. 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
10. 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.)
11. Do you currently hold, or have you ever held, a professional license or certificate 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 certificate held, provide the date(s) held and the number(s). If the license or certificate was issued under
a different name, please provide that name. _________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certificate Number State or jurisdiction that issued the license or certificate Date issued/expire
12. Have you ever been disciplined or denied a professional license or certificate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
13. Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
14. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice by any
agency or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. Have you ever been named as a defendant in any litigation related to the practice of dentistry or other
professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
16. Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
17. 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
18. 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 dentistry 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 12 through 18, 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.
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
Yes
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signature
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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 sufficient 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 qualifications 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, 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
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signature
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New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
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
New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Verication of State License
A separate form must be used for each state.
(This form may be reproduced.)
Name of applicant: _______________________________________________________________________________________
Last name First name Middle initial
The above-named applicant is a licensee of the State of ____________________________________________ and was issued
license number ________________________________on___________________________________________ .
Month Day Year
The applicant was licensed by:
Date passed Date passed
State examination ____________________ Based on Parts I & II
N.E.R.B. ____________________ of the National Board ________________________
W.R.E.B. ____________________ Endorsement/Reciprocity
S.R.T.A. ____________________ from the State of ________________________
C.R.D.T.S. ____________________
Other ____________________
The license status is:
Current and in good status expiring on ________________________ Revoked or suspended
Date
Inactive/expired on ________________________ Other (please attach explanation)
Date
Examination History (if applicable)
Date of examination Subject Grade
____________________________________ ______________________________________________ _______________
____________________________________ ______________________________________________ _______________
The licensee does does not have a record of disciplinary history with this agency. (Attach additional information if applicable.)
I hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record of the individual on this form.
__________________________________________________
Name of Board
__________________________________________________
Name of person completing this form
__________________________________________________
Title
__________________________________________________
Signature
(Board Seal)
Form SV1
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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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