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

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

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 57 minutes to complete

The Instructions for Reinstating/Reactivating a License (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 18 pages long and contains:

  • 6 signatures
  • 66 check-boxes
  • 172 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Chiropractic Examiners
124 Halsey Street, 6th Floor, P.O. Box 45004
Newark, New Jersey 07101
(973) 504-6395
Instructions for Reinstating/Reactivating a License
Pursuant to the provisions of the Uniform Enforcement Act (N.J.S.A.45:1-7.2), all licensees of the Division of Consumer Affairs are
required to complete the enclosed application form in order to reinstate a license. The following additional items are required
to complete the reinstatement process:
1. If your license is currently in an “expired” status, you will be required to pay the reinstatement fee plus the current biennial
license renewal fee and, if your license expired prior to the current licensing period, the immediate past biennial license
renewal fee.
If your license has been in expired status for more than one renewal period, the immediate past biennial license renewal
fee must be paid in addition to the reinstatement fee and current biennial renewal fee.
Expired Status
Reinstatement Fee $125.00
Current Biennial License Renewal Fee $350.00
Immediate Past Biennial License Renewal Fee $350.00
If your license is currently in an “inactive” / “retired” status, you will be required to pay:
Inactive / Retired Status
Biennial License Renewal Fee $350.00
2. Contact every state in which you have or have held a license to practice chiropractic. Request that a written verication
be forwarded to the State Board of Chiropractic Examiners at the address noted above. List all these states on the enclosed
application.
3. Criminal History Background Check - If you have completed the ngerprinting process for any Board or Committee of the
New Jersey Division of Consumer Affairs since 2003, you must submit a fee of $.5 with your completed Certication
and Authorization for a Criminal History Background Check form. If you have not been ngerprinted since 2003, do not
submit the $20.25 fee; you will receive a separate mailing from the Division regarding the criminal history background
process.
4. A check of the CIN-BAD (Chiropractic Information Network - Board Action Database) operated by the Federation of
Chiropractic Licensing Boards will be processed by the Board ofce to insure that no action has been taken against your
license by any other jurisdiction.
5. If, after a review of your application for reinstatement or reactivation, the Board determines that you may have practice
deciencies in need of remediation prior to reinstatement or reactivation of your license, the Board may require you to
submit to and successfully pass an examination or assessment of your skills, a refresher course, or any other requirement
that the Board determines is necessary prior to reinstating or reactivating your license. If that examination or assessment
identies clinical deciencies or educational needs, the Board may require, prior to reinstating or reactivating your license,
that you take and successfully complete education or training, or submit to supervision, monitoring, or limitations, as the
Board determines are necessary to assure that you practice with reasonable skill and safety. The Board may, in its discretion,
restore your license as long as you complete the training within a period of time prescribed by the Board following the
restoration of your license.
6. Submission of proof of completion of the continuing education credits for the biennial registration period immediately prior
to the current biennial registration period. The continuing education requirements may be found at N.J.A.C. 13:44E-1A.5.
7. If you have a valid, corresponding license in good standing issued by another state, and you submit proof that you satised
that state’s continuing education requirements for that license, you will be deemed to have satised the continuing education
credits required to reinstate/reactivate your license. If there are specic courses required to satisfy the continuing education
requirements for New Jersey, you may take these courses in the 12 months following reinstatement or reactivation.
8. Submission of a written statement indicating that you will obtain coverage by chiropractic malpractice insurance once
license to practice in New Jersey is reinstated.
Mail to: State Board of Chiropractic Examiners
P.O. Box 45004
Newark, NJ 07101
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Chiropractic Examiners
124 Halsey Street, 6th Floor, P.O. Box 45004
Newark, New Jersey 07101
(973) 504-6395
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 payable to the State of New Jersey. (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).
License number: ______________________________________ Date of last renewal: ____________________________
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:
Reinstated
Reactivated.
For ofce use only
Application number:
____________________
Reinstatement date:
____________________
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. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certicate unless you provide the
required documents concerning the plan for repayment of your student loan.
6. 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
click to sign
signature
click to edit
7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical 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 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 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 of the Fifth Amendment, provided that
the Attorney General rst grants you immunity afforded by statutory law. (N.J.S.A. 45:1-20.)
“Ability to practice as a chiropractor” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of a chiropractor, 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 ampliers; and
c. The physical capability to perform the duties of a chiropractor, 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, specic 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 eld 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 dened 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 certicate should be issued, whether conditions should be imposed or
whether you are not eligible for reinstatement/reactivation of licensure or certication.
___________________________________________ ___________________________________
Applicant’s signature Date
click to sign
signature
click to edit
8. 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.
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 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.)
11. 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 chiropractor
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 Chiropractic Examiners.
12. Have you ever been disciplined or denied a chiropractor’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
13. 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
14. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice
by any agency or certication 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 chiropractic 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 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
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 chiropractic 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.
Employment since your license expired, was suspended or was placed in inactive status.
(You may photocopy this page if necessary.)
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: _____________________________________________________________________________
Provideastatement(below)indicatingwhetheryouwereengagedinthepracticeofyourprofessionoroccupationinNewJersey
duringtheperiodthatyourNewJerseylicenseorcerticatewaslapsed.Ifyouwerepracticingyourprofessionaloroccupation
duringthislapsedlicenseperiod,youmustincludeadescriptionofthetypeofworkorprojectswithwhichyouwereinvolved.
 _____________________________________ ____________________________________ _______________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
click to sign
signature
click to edit
Continuing Education Tracking Form
Attention: It is the licensee’s responsibility to present the following information to the Board in a manner that is both organized and readable. Verication of attendance
certicates shall be inscribed with the number of the line where the course appears on this form. Photocopies of your verication of attendance certicates must be
submitted with this document. Print or type each entry and provide documentation of attendance in the same order that is listed below. If the New Jersey State Board of
Chiropractic Examiners (NJSBCE) ID # is not available and the course has not been pre-approved by the NJSBCE, a course outline and curriculum vitae of all speakers
must be included with the verication of attendance. This form must be signed before submission. Incomplete, illegible, or improperly submitted forms will be returned
to the licensee for resubmission.
_____________________________________________________ __________________________________________________
Print name N.J. License No.
No.
Date of
Course
NJBCE
Board ID#
Complete Course Title Afliation/College
Total # of
Credits
Course Type
Live, Online, Webinar,
Other (explain)
Please note if
course includes
Nutrition or
Documentation
1
2
3
4
5
6
7
8
9
10
The courses and verication of attendance certicates submitted above are evidence of my personal attendance at the course listed. My signature attests that the
submission is accurate and I understand that a false submission may result in a monetary penalty or suspension of license to practice chiropractic.
______________________________ __________________________________________ ____________________________________________________
Date Telephone No. (include area code) Signature
You may photocopy the continuing education tracking form.
click to sign
signature
click to edit
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
click to sign
signature
click to edit
New Jersey Ofce of the Attorney General
DivisionofConsumerAffairs
StateBoardofChiropracticExaminers
124HalseyStreet,6thFloor,P.O.Box45004
Newark,NewJersey07101
(973)504-6395
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terminationofprobationorder,ifapplicable,must besubmittedwiththisform.Anydocuments(includingemployer
orsupervisorlettersofreference,ifapplicable)whichpresentclearandconvincingevidenceofrehabilitationmust besubmitted
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
___________________
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document