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 Veterinary Medical Examiners
124 Halsey Street, 6th oor, P.O. Box 45020
Newark, New Jersey 07101
(973) 504-6500
Instructions for Reinstating/Reactivating a 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: 1-7.2a, b, c and d. The necessary application
and materials for applying for reinstatement/reactivation are enclosed.
1. Completeandreturn:
• The enclosed Application for Reinstatement/Reactivation.
• The enclosed Certicate and Authorization Form for a criminal history background
check.
2. Enclose:
• Payment of a reinstatement fee of $250.00
• Payment of the renewal fee of $250.00 for each period of lapsed licensure (for
reinstatements).
3. Submit:
• If you have held a license in another state during the lapsed licensure period,
you are also required to submit a letter of good standing from all of the states
in which you are or have been licensed to practice veterinary medicine; and
(See page 4)
• A signed and dated certification of employment listing each job held during
the lapsed licensure period. This certification of employment must include
the names, addresses and telephone numbers of each employer; (See page 5)
• Proof of completion of continuing education courses. (See page 6)
4. Mailto: State Board of Veterinary Medical Examiners
P. O. Box 45020
Newark, NJ 07101
Ifyourlicensehasbeen“expiredorinactive”formorethan5years,youmustalsosuccessfullycomplete
theNewJerseyStateJurisprudenceOrientationProgram.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Veterinary Medical Examiners
124 Halsey Street, 6th oor, P.O. Box 45020
Newark, New Jersey 07101
(973) 504-6500
Application for Reinstatement/Reactivation
Date: ______________________________
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 Board of Veterinary Medical Examiners. (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/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 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
Check one:
I am applying to have my
license to practice veterinary
medicine:
Reinstated
Reactivated.
1
3. Social Security Number
You mustdisclose your Social Security number for the reasons stated below. Failure to do so may result in the denial of reinstatement/
reactivation of licensure or certication.
*Social Security Number: __________- _________ - _________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board 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 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
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 may result in a denial of reinstatement/
reactivation 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
2
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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
3
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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
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 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 veterinarian
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 State Board of Veterinary Medical Examiners.
11. Have you ever been disciplined or denied a veterinarian’s 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
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 fines 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 veterinary medicine 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 veterinary medicine 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 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
4
(You may photocopy this page if necessary.)
since your license expired or was placed in inactive status. Employment
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to ______________________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to ______________________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
Employer: ______________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________ (include area code) Hours per week: _____________________
Your major responsibilities (use additional sheets of paper if necessary):
Employed from ____________________________ to ______________________________
Month Year Month Year
Immediate supervisor’s name: _______________________________________________________________________________
___________________________________ ___________________________________ ________________________
Applicant’s signature DateApplicant’s name (please print)
5
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signature
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ContinuingEducation
Please list all of the courses that you have successfully completed since your license expired or was supended.
Date Title Subject matter Sponsor
No. of
hours
Please attach copies of the certicates of completion for each course listed.
6
7
CertifiCation for
reinstatement/reaCtivation appliCation
I, _______________________________________________________ , in making this application to the Board for reinstatement/
reactivation of 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 reinstatement/reactivation or to withhold renewal of or suspend or revoke a certicate or license issued
by the Board.
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.
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.
___________________________________ ______________________________________________
Date Signature of applicant
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signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Veterinary Medical Examiners
P.O. Box 45020
Newark, New Jersey 07101
(973) 504-6500
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.
Continuation on the reverse side ➨
Mr.
Mrs.
Ms.
Ofcial Use Only
Resubmit
_________________
Board or Committee
_________________
Ofcial Use Only
Dual License
License Type 1
___________________
Applicant’s Number
___________________
License Type 2
___________________
Applicant’s Number
___________________
Rev. 1/2/19
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
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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 15 August 2020

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