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 Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Instructions for Reinstating/Reactivating a License
In accordance with the Uniform Enforcement Act, a professional or occupational license or certicate may be reinstated/
reactivated, 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 Authorization Form for a Criminal History Background Check.
2. Enclose:
Forreinstatements
• Payment of a reinstatement fee of $175.00; and
• Payment of the appropriate renewal fee ($500.00 for technologists or $150.00 for technicians).
Forreactivation
• Payment of $500.00 (technologists) or $150.00 (technicians) for the current licensure period.
3. Submit:
a. A signed and dated certication of employment listing each job held during the lapsed licensure or
certication period. This certication of employment must include the names, addresses and telephone
numbers of each employer. (If you are currently unemployed or employed in a setting which is clearly
unrelated to the eld of polysomnography, please indicate this fact.)
b. Proof that you completed the continuing education credits required for each biennial licensure period
during which the license was not active.
c. A written request to the Board indicating why you are able to recommence acting as a trainee, technician
or technologist, as appropriate.
d. Proof that you hold current certication in Basic Life Support for the Healthcare Provider from the American
Heart Association or Cardio Pulmonary Resuscitation/Automated External Debrillator (C.P.R./A.E.D.) for
the Professional Rescuer from the American Red Cross.
e. If you are a trainee or a technician, proof that you will be supervised by a licensed polysomnographic
technologist or a licensed physician while acting as a polysomnographic trainee or technician.
f. If you are a technician seeking to reinstate your license, you must provide proof that you completed 100
sleep studies in a facility that is provisionally or fully accredited by A.A.S.M.
Note
A licensee whose license has been automatically suspended (expired) for more than ve (5) years who wishes to return
to practice shall reapply for licensure and shall demonstrate that he or she has maintained prociency in the eld of
polysomnography. An applicant who fails to demonstrate to the satisfaction of the Board that he or she has maintained
prociency while the license was lapsed may be subject to an examination or other requirements as determined by the
Board prior to reinstatement/reactivation of his or her license (N.J.A.C. 13:44L-3.2(f)).
4. Mailto: State Board of Polysomnography
P. O. Box 45051
Newark, NJ 07101
Uponreviewandapprovalofyourreinstatement/reactivationapplicationandcriminalhistorybackgroundcheckresults,
alicenseorcerticatewillbeissued.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Application for Reinstatement/Reactivation of a License
N.J. License/Certificate No.: ______________________________ Type of License/Certificate: ____________________________
Initial License/Certificate Date: ___________________________ Y
ear of last renewal: ____________________________
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
Please indicate below the
type of action you wish to
initiate.
Reinstatement
Reactivation
Attach a clear, full-face passport
photograph (2”x2”) of your head
and shoulders, takenwithinthe
pastsixmonths.
A photo is required with each
application.
Do not use staples to attach the
photo.
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
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
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
11. Have you ever been disciplined or denied a license or certicate to practice polysomnography, or any other type of 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 nes or other penalties) ever been taken against your professional practice
by any agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
14. Have you ever been named as a defendant in any litigation related to the practice of polysomnography 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 polysomnography or other professional practice in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 11 through 17, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
Employment since your license expired or became inactive.
(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: _____________________________________________________________________________
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 name (please print) Applicant’s signature Date
Continuing Education
Please list all of the courses that you have successfully completed since your license expired or became inactive. In addition,
you must provide a copy of the Certicate of Completion for every course you have taken.
Date Title Subjectmatter Sponsor
No.of
hours
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
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
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
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 mustbe 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
___________________
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.1/1/19
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Sleep Studies for Technologist Reinstatement
I attest that ____________________________________________has completed ____________ sleep studies as a
(Name of applicant) (No. of studies)
licensed polysomnographic technician over the last _________ months beginning __________ ending __________
(No. of months) (MM/DD/YY) (MM/DD/YY)
at ________________________________________
, ________________________________________________________
(Name of facility) (Street address, City, ZIP code)
____________________________ which is provisionally or fully accredited by the American Academy of Sleep Medicine (AASM).
(Telephone number - include area code)
____________________________________________________
Print name of licensed polysomnography technologist
or qualied medical director
____________________________________________________ ____________________________________
Signature of licensed polysomnography technologist Date (MM/DD/YY)
or qualied medical director
____________________________________________________ ____________________________________
License number of licensed polysomnography technologist Date of license expiration (MM/DD/YY)
or qualied medical director
Pleasenote:
N.J.A.C. 13:44L-1.2 denes a “qualied medical director” as a licensed physician who is either eligible for board certication
or is board certied in sleep medicine by the American Board of Sleep Medicine, or a certication board recognized by the
American Board of Medical Specialties which bases its certication in sleep medicine upon the sleep medicine examination
created by the American Board of Internal Medicine, and who acts as the medical director of any:
1. In-patient or out-patient sleep center or laboratory provisionally accredited or fully accredited by the AASM or
accredited by a Joint Commission;
2. Ambulatory care facility or general acute care hospital licensed by the Department of Health and Senior
Services;
3. Home health agencies, assisted living residences, comprehensive personal care homes, assisted living programs
and alternate family care sponsor agencies licensed by the Department of Health and Senior Services; or
4. Health care service rms registered with the Division of Consumer Affairs.
N.J.A.C. 13:44L-3.3(c)4 Documentary proof signed by a supervising polysomnographic technologist or qualied medical director
indicating that, within the last year, the applicant has completed at least 100 sleep studies in a facility that is provisionally or
fully accredited by AASM.
(Attachadditionalcopiesasnecessary.)
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 6th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Technician/Trainee Supervision Form
Tobecompletedbythesupervisorofeachfacility.
Asupervisorisdenedasalicensedpolysomnographictechnologist
oraqualiedmedicaldirector(asdenedinN.J.A.C.13:44L-1.2).
_____________________________________________, who is licensed as a physician or polysomnographic
(Name of supervisor)
technologist in New Jersey, will act as primary supervisor for _____________________________________________
(Name of applicant)
and is aware that he or she, or another physician or polysomnographic technologist licensed in New Jersey,
shall be continuously on-site and available, either on-site or through voice or electronic communication whenever
___________________________________________is acting as a polysomnographic technician/trainee.
(Name of applicant)
_________________________________________will maintain a record of the name and license number of the licensed
(Name of supervisor)
physician or polysomnographic technologist/trainee who is supervising _____________________________________
(Name of applicant)
while he or she is acting as a polysomnographic technician/trainee.
_______________________________________________ _______________________________________
Print name of supervisor Name of applicant
_______________________________________________ _______________________________________
Signature of supervisor Signature of applicant
_______________________________________________ ______________________________________
Date Date
_______________________________________________
License number of supervisor
Facility’s name: _______________________________________________________________________________
Facility’s address: ______________________________________________________________________________
Street City State ZIP code
Facility’s telephone number: ________________________________ (include area code)
(Attach additional copies as necessary.)
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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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