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

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Instructions for Reinstating/Reactivating a License/Certicate New Jersey Ofce (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 Social Work Examiners
124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101
(973) 504-6495
www.njconsumeraffairs.gov/sw
Instructions for Reinstating/Reactivating a License/Certicate
In accordance with the Uniform Enforcement Act, a profesional 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
provision of N.J.S.A. 45:1-7.
1. Submit:
a. A completed application for reinstatement/reactivation.
b. Proof that you have completed continuing education courses for the immediately preceding renewal period, as
required by N.J.S.A. 45:6-15BB-9 and N.J.A.C. 13:44-6. Acceptable proof would include, but is not be limited
to, a copy of your course completion certicates.
c. Certication of employment listing each job held during the period of suspended or inactive licensure or certication.
d. A completed Certication and Authorization form for a criminal history background check.
e 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 “Inactive,” status, you
must pay only the current renewal fee. If your license is currently in “Expired” status, you must pay the
reinstatement fee, the current renewal fee and the renewal fee from the immediately preceding renewal period.
Information on where to obtain the required continuing education, please visit www.aswb.org/newjersey or www.nasw.org-nj .
2. Mail completed application to: State Board of Social Work Examiners
P.O. Box 45033
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.
CSW
Reinstatement Fee (only if expired) $ 150.00
Current Renewal Fee $ 70.00
Preceding renewal fee (only if expired)
$ 70.00
Fingerprint Resubmit Fee $ 18.75
Continuing Education Courses - 20 hours including
5 hours in Ethics and 3 hours in Cultural
Competency
LSW
Reinstatement Fee (only if expired) $ 150.00
Current Renewal Fee
$ 120.00
Preceding renewal fee (only if expired)
$ 120.00
Fingerprint Resubmit Fee $ 18.75
Continuing Education Courses - 30 hours including
5 hours in Ethics and 3 hours in Cultural
Competency
LCSW
Reinstatement Fee (only if expired) $ 150.00
Current Renewal Fee
$ 160.00
Preceding renewal fee (only if expired)
$ 160.00
Fingerprint Resubmit Fee $ 18.75
Continuing Education Courses - 40 hours including
5 hours in Ethics and 3 hours in Cultural
Competency
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Social Work Examiners
124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101
(973) 504-6495
www.njconsumeraffairs.gov/sw
Application for Reinstatement or Reactivation of a Social Worker
New Jersey License or Certicate
You may not practice in the State of New Jersey until your license or certicate is reinstated/reactivated,
unless in an exempt setting according to N.J.S.A. 45:15BB-5.
N.J. License No.: ______________________________________
Please submit with this application a check or money order made payable to the State of New Jersey in the amount corresponding
to your application category. (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 or reactivation 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 reinstatement
or 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 Committee
is required to obtain your Social Security number. Pursuant to these authorities, the Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for
the purpose of reviewing compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses, registrations 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 questions a(1) through d will result in a denial of reinstatement
or reactivation 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
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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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7. 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
8. 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.)
9. 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. _________________________________________________________________
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/expired
Note: If you are licensed or certied as a social worker in any other state, the District of Columbia or in any other jurisdiction, it is your
responsibility to contact the licensing board in that jurisdiction to request that verication of your licensure or certication be sent
directly to the New Jersey State Board of Social Work Examiners.
10. Have you ever been disciplined or denied a social work license or certicate or any other professional license or certicate in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
11. 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
12. 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
13. Have you ever been named as a defendant in any litigation related to the practice of social work or other professional practice
in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
14. 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
15. 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
16. 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 social work 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 10 through 16, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Employment since your license expired or became inactive. (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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CertifiCation for reinstatement/reaCtivation appliCation
I, ________________________________________________ , in making this application to the Board or Committee for
reinstatement of certification 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 reinstatement or reactivation 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 reinstatement or 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
Sworn and subscribed to before me this __________________
Afx Seal Here
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Social Work Examiners
124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101
(973) 504-6495
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 LicenseCerticate New Jersey Ofce (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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