Fill - Free fillable Instructions for completing the license application for a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) PDF form

Instructions for completing the license application

for a New Jersey Podiatry License

Read the application and instructions before completing the application.

Each section of the application is explained in these instructions -follow them carefully.

Completing the enclosed application and mailing it to the Board office does not constitute the

completion of your application. You must request verifications and certifications from schools,

employers, etc.(third parties) using forms enclosed in this packet and follow-up with the third

parties to ensure materials are sent directly to the Board office. Do not substitute a different

form/document for the one requested or those provided with the application. Your application

cannot be reviewed and approved until all documentation regarding your education, post-

graduate training and professional experience are received. Request verification from all

third parties immediately. Get them expedited, if possible.

The application must be submitted with a certified check or money order in the amount of

$125.00 (nonrefundable) and three photographs which must be signed and dated. An

endorsement fee and registration fee will be requested just prior to your license being issued.

Your application reviewer will inform you regarding how much is owed when it is due.

Type or print neatly. All questions must be answered. For “Yes” or “No” questions, circle the

correct answer. If you determine a question does not apply to you, please indicate that fact by

writing “N/A” as your response. When space provided is insufficient, attach additional sheets of

paper. Print your first name, middle initial and last name on each page of the application and on

each attachment. Attachments are considered part of your application.

Due to confidentiality restrictions, information about the status of your license application

can only be discussed with you unless you provide written authorization for it to be discussed

with another interested party. This restriction includes your spouse and/or family members.

Please note -if you are using a independent credentialing service to assist with the submission of

elements required for your application, you are still required to complete every section of the

application and ensure all third-party forms are completed and returned directly to the Board.

Applicants choosing to utilize the Federation Credentials Verification Service (FCVS) should refer

to FAQs found under the Applicants heading on the home page of this web site to find which

application elements will be met by the Board’s receipt of an FCVS packet on your behalf.

When preparing your curriculum vitae, be complete and accurate. You must account for all

periods of time beginning with your entry into medical school.

When the Board has received your application, fee and third-party documentation, your file will

be reviewed. At that time, you will be notified of any additional information or clarification that

may be required to complete your application. Should you have questions about the application,

or process, please contact the Board by telephone at 609.826.7100, by fax at 609.984.3930 or

by e-mail at mailto:bmeapp@dca.lps.state.nj.us.

Falsification or misrepresentation of any item or response on this application or any

attachment hereto is sufficient basis for denying a license.

Please do not return these instructions to the Board with your application!

1. Print your legal name. This is the name that will appear on your license certificate. If you

have changed your name, submit a copy of the associated legal document with this

application. Print your current first name, middle initial and last name on the copy of the

legal document.

2. Print any other name which may appear on documents you submit, or others may submit as

part of this application (i.e., maiden name, legal name change, etc.). If you have changed

your name, submit a copy of the associated legal document with this application. Print your

current first name, middle initial and last name on the copy of the legal document.

3. Print your current mailing address and contact information. Your mailing address cannot be

a post office box unless you also enter your street address. Application reviewers will contact

you via e-mail, and follow-up in writing to your mailing address. It is your responsibility to

notify the Board immediately, in writing by mail or FAX, of changes to your mailing address.

You may also provide an Address of Record and home/business addresses (attach to

application). The Address of Record will be printed on your license certificate. If you do not

provide an Address of Record before becoming licensed, your mailing address will be printed

on your license certificate. Your name and address will be posted on the Online License

Directory. As a matter of information, under New Jersey public disclosure law, any of your

license addresses must be provided if requested under the Open Public Records Act.

4. Enter your date and place of birth. Federal law limits the issuance or renewal of professional

licenses to U.S. citizens or qualified aliens. To comply with federal law you must provide

evidence of citizenship status. If you were born in the United States, submit a copy of

your birth certificate or passport with this application. If you were born elsewhere,

submit a copy of your passport or a copy of an official document granting citizenship status.

If you are not a U.S. citizen, submit a copy of the official immigration document authorizing

you to work in the United States. Questions about your immigration status and whether it is

a qualifying status under federal law should be directed to the U.S.C.I.S. at (800) 375-5283.

5. Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey Child Support Enforcement Law,

N.J.S.A. 54:50-25 of the New Jersey Taxation law, and Section 1128E(b)(2)A of the Social

Security Act, the Board is required to obtain your Social Security number. The Board is

further obligated to provide your Social Security number to the Director of Taxation, the

Probation Division or any other agency responsible for child support enforcement, upon

request, and to the National Practitioner Data Bank and the H.I.P. Data Bank when reporting

adverse actions.

Pursuant to the Federal Privacy Act (5 U.S.C. Section 55a(note(b)), the Board is requesting

your consent to use your Social Security number for the following purposes: 1) to verify

identity; 2) to aid in the collection of financial obligations due and owing the Board or any

other State agency; and 3) to aid in the disclosure to State or federal law enforcement and

licensing officials and agencies of information obtained in investigations pertaining to

licensure and disciplinary proceedings.

6. Circle Yes or No. If “Yes,” enter the type of license/registration for which you applied, and

the date you applied (month/year).

Pre-Podiatry Education

Answer the questions by circling yes or no.

Print the information requested for each college/university you attended. Enter the dates in the

following format: From Month/Year -To Month/Year.

Podiatry Education

List every podiatry school in which you were ever enrolled EVEN IF NO CREDIT WAS

GRANTED OR NO CREDIT WAS SOUGHT FOR THE STUDY. Enter your full name at the

top of form BME-PEV and mail a copy of the form to every school you attended -not

just the school from which you graduated. Direct the school(s) to return the form with an

official transcript directly to the N.J.B.M.E. address on the form. Forms submitted by you will

not be accepted -they must be mailed directly from the school to the N.J.B.M.E.

Board Certifications -Complete by entering the required information for each certification you

hold.

Endorsement Examinations

N.B.P.M.E. Exam -Enter dates for each part of the National Board of Podiatric Medicine Exam

taken. You must pass each subject in both parts of the N.B.P.M.E. Exam to be considered for

licensure. Complete Section 1 of the Form BME-VSL and mail it to the National Board of Podiatry

Examiners (www.npbme.org). Direct them to complete Sections 2 and Section 4 and return it

directly to the N.J.B.M.E. at the address on the form.

Sister State -To be eligible for Sister State Endorsement, a candidate must have held the license

that was granted on the basis of the Sister State examination for a minimum of five years. The

candidate must have practiced, without interruption, in the State where the examination was

taken for the five years immediately prior to submission of an application to the State of New

Jersey. If you meet these conditions, enter the State and date that you passed their exam.

Complete Section 1 of the Form BME-VSL and mail it to the State’s Board of Examiners. Direct

them to complete Sections 2, 3 and 4, and return it directly to the NJBME at the address on the

form.

Postgraduate Training

List each training program (including internship, residency, fellowship) in which you have

participated and the information requested on the form for each program. Enter your full name

at the top of Form BME-VPT and mail a copy of the form to each training program you list

whether you received credit, no credit or partial credit. Direct the training program to mail the

form directly to the N.J.B.M.E. at the address on the form.

Section Three -Employment/Malpractice History/Other Licenses Privileges/

Affiliation/Employment/Appointments History

Print the required information for every employee (hospital or non-hospital) private office,

H.M.O., etc. where you were employed or with whom you were affiliated for the five-year period

that immediately precedes the filing of this application. Enter your full name at the top of Form

BME-PEA and mail a copy of the form to every entity you have listed in this section of your

application.

Malpractice History

Answer all of the questions. Attach a written statement identifying every malpractice suit in

which you have been listed as a defendant. Include the name of the plaintiff, date of the incident

and status of each suit, i.e. open, dismissed, closed with payment. Provide your personal

description of the clinical aspects of the case as it would be explained to a fellow professional

and a copy of the Complaint or Bill of Particulars. If the malpractice suit has been closed, you

must provide a copy of the Final Disposition including the amount of payment on your behalf.

Failure to provide this information when submitting your application will delay your application

review. If a malpractice carrier has taken an action with reference to you or your

policy, you must submit an explanation and documentation of the action from the

carrier.

Enter your full name at the top of Form BME-MI and forward a copy of the form to every

malpractice insurance carrier which has provided coverage to you during the three-year period

immediately preceding the submission of your license application. If your malpractice coverage

is/was provided by a hospital, forward the form to the Risk Management office of the hospital.

Direct the hospital and insurance carriers to mail the form directly to the N.J.B.M.E. -forms

submitted by you will not be accepted.

Verification of State License

Print the required information for each license and/or permit ever held in another state. For

each license or permit held, no matter the status, complete Section 1 of Form BME-VSL and

mail the form to the state which granted it. Direct them to complete Section 2 and 4 and mail it

directly to the N.J.B.M.E.

Note: All applicants meeting the Postgraduate Training criteria detailed in Section Two

of these instructions, who have never held a plenary medical license in any other state

or jurisdiction, are not required to submit forms BME-PEA, BME-MI and BME-VSL.

Section Four -Character, Ethics and Medical Conditions Information regarding

moral character and ethical professional responsibility

Answer all questions by circling either Yes or No. For all “Yes” answers, attach a full

explanation and any pertinent documentation. Print your first name, middle initial and

last name on each page of any attachment.

Question a. asks about any arrests, charges or offenses you may have committed.

Carefully review the following definitions and instructions before answering

the question. Definitions for the purpose of this question:

“Arrest” includes any detaining, holding or taking into custody by any police or other

law enforcement authorities to answer for the alleged performance of any “offense.”

“Charge” includes any indictment, complaint, information, summons, or other notice of

the alleged commission of any “offense.”

“Offense” includes all felonies, crimes, high misdemeanors, misdemeanors, disorderly

persons offenses, petty disorderly offenses, driving while intoxicated/impaired motor

vehicle offenses, violations of probation or any other court order, and local ordinance

violations.

Instructions for the purpose of question a. Answer “Yes” and provide all information to the best

of your ability EVEN IF:

1. You did not commit the offense charged;

2. The charges were dismissed or subsequently downgraded to a lesser charge;

3. You completed a Pretrial Intervention (P.T.I.) or equivalent diversionary program;

4. You were not convicted;

5. You did not serve any time in prison or jail; or

6. The charges or offenses happened a long time ago.

Answer “No” IF:

1. You have never been arrested or charged with any crime or offense;

2. The records relating to a charge, an arrest or conviction have been expunged by the court or

a government agency.

Questions h. through k. -Under N.J.S.A. 2A:17-56-44d, an answer of “Yes” to any of questions

h.(a), h.(b), i., j., k. will result in a denial of licensure. Furthermore, any false certification of

these questions may subject you to a penalty, including, but not limited to, immediate

revocation or suspension of licensure.

Medical Conditions/Chemical Substances

Answer all questions by circling “Yes,” “No” or “Not Applicable” (N/A), unless you are asserting

your Fifth Amendment Privilege against self-incrimination. If you are asserting your Fifth

Amendment Privilege, write that in the space under the first paragraph on the page.

If you are answering the questions, attach a detailed explanation for answers of “Yes,” and

include your printed first name, middle initial and last name on each page of the attachment.

For the purposes of these questions, the following phrases or words have the following

meanings:

“Ability to practice podiatry” is to be construed to include all of the following:

1. The cognitive capacity to make appropriate clinical diagnoses and exercise reasoned medical

judgments and to learn and keep abreast of medical developments; and

2. The ability to communicate those judgments and medical information to patients and other

health care providers with or without the use of aids or devices, such as voice amplifiers; and

3. The physical capability to perform medical tasks 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 orthopedic, visual, speech and hearing impairments, cerebral palsy,

epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental

retardation, emotional or mental illness, specific learning disabilities, H.I.V. disease,

tuberculosis, drug addiction and alcoholism.

“Chemical substances” is to be construed to include alcohol, drugs or medications, including

those taken pursuant to a valid prescription for legitimate medical purposes and in accordance

with the prescriber’s direction, as well as those used illegally.

Section Four -Character, Ethics and Medical Conditions (continued)

“Currently” does not mean on the day of, or even in the weeks or months preceding the

completion of the 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 past two years.

“Illegal use of controlled substances” means the use of controlled dangerous substances

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.

Documents to be completed and/or returned with your application:

1. Certification and Authorization Form for a Criminal History Background Check

The New Jersey Division of Consumer Affairs is required to conduct criminal history record

background checks of all health care professionals prior to the issuance of an initial license

to practice a health care profession (N.J.S.A. 45:1-28 et seq.). In order for the Division to

conduct a criminal history record background check, you must complete the enclosed

Certification and Authorization form and return the form with your license application. Upon

receipt, the Board will mail you the information you will need to undergo the criminal history

background check. The Board will forward to you information you will need to schedule an

appointment to have your fingerprints electronically recorded if you work/reside in New

Jersey, or live in a community near the State’s borders (go to

www.njconsumeraffairs.gov/chbc/ZipCodeList.pdf on the Web for a complete list of the ZIP

codes of these nearby communities). The recording of your fingerprints is necessary to

conduct the criminal history background check. If you do not live in a community near the

State’s borders, you will be sent information on your options for having your fingerprints

recorded.

2. Waiver and Certification -Print your first name, middle initial and last name at the top of

the form. Read, complete and sign the form in the presence of a Notary Public. Applications

must be submitted to the N.J.B.M.E. within 30 days of notarization. The Board considers all

information submitted to be the responsibility of the applicant. Please ensure that all of the

information being submitted is accurate and complete.

3. Curriculum Vitae -Submit a copy of your curriculum vitae with your application. List all

activities chronologically, with the month and year dates for the beginning and ending of

each period of your podiatry education, postgraduate training, professional experiences and

activities. The list must begin with the first podiatry school in which you were enrolled and

continue through to the present date with no gaps. Label all periods of unemployment as

such, and identify your activities during any period of unemployment. Provide addresses for

all employers.

4. Photographs -Submit three passport-size professional photographs with your application.

The photographs must not be more than six months old and must be signed and dated.

5. Form BME-PEV -Enter your full name at the top of this form and mail a copy to each school

you attended whether credit was earned or not. The school must return the form directly to

the N.J.B.M.E. with an official transcript. Keep track of the forms you mail, and follow-up

with the school(s) to ensure the form is completed and mailed in a timely fashion.

6. Form BME-VPT -Enter your full name at the top of this form and mail a copy to each

training program in which you participated whether credit was earned or not. The facility

must return the form directly to the N.J.B.M.E. Keep track of the forms you mail and follow-

up with the facility(ies) to ensure the form is completed and mailed in a timely fashion.

7. Form BME-PEA -Enter your full name at the top of this form and mail a copy to each facility

at which you worked or with whom you are or have been affiliated. The facility must return

the form directly to the N.J.B.M.E. Keep track of the forms you mail, and follow-up with the

facility(ies) to ensure the form is completed and mailed in a timely fashion.

8. Form BME-MI -Enter your full name at the top of this form and mail a copy to each medical

malpractice insurance carrier from whom you have obtained medical malpractice insurance,

and/or to the Office of Risk Management for each hospital with whom you have been

affiliated or employed. The malpractice insurance carrier and/or the hospital must return the

form directly to the N.J.B.M.E. Keep track of the forms you mail, and follow-up to ensure the

form is completed and mailed in a timely fashion.

9. Form BME-VSL -Make copies of the form and complete the top section for each state where

you have taken a written examination, or have held a license to practice podiatry whether

the license is in active, inactive or some other status. The state must complete the

appropriate sections of the form and return it directly to the N.J.B.M.E. Keep track of the

forms you mail, and follow-up to ensure the form is completed and mailed in a timely

fashion.

10. Federation of Podiatric Medical Boards Disciplinary Report -Request the organization

send your report to the N.J.B.M.E. The F.P.M.B.’s web site is www.fpmb.org.

11. Name Change -If your name as it appears on your podiatric school diploma is not the same

as it appears on documentation submitted, include a copy of the legal document effecting

this change. Print your current first name, middle initial and last name on the copy of the

document.

Use these addresses when sending documents to the N.J.B.M.E.

Mailing Address: via U.S. Postal Service - via other mail delivery service

New Jersey Board of Medical Examiners New Jersey Board of Medical Examiners

140 East Front Street -3

rd

Floor 140 East Front Street -3

rd

Floor

P.O. Box 183 Trenton, NJ 08608

Trenton, NJ 08625.

Application for Podiatry Licensure by the

State Board of Medical Examiners of New Jersey

This entire application must be typed or legibly printed.

Section One - DEMOGRAPHICS

1. Name ________________________________________________________________

First Middle Initial (M.I.) Last

2. List any other name which may appear on documents submitted as part of this

application (See Instructions).

___________________________________

__________________________________

3. Contact Information

E-mail address ___________________@________

Mailing address (This may

not be a post ofce box.)

_____

________________________________________________________________

Street City State/Country ZIP/Postal Code

(________)__________________ (_______)_________________

Area Code Telephone Number Area Code Cell Phone Number

(_______ )___________________ (_______)_________________

Area Code Work Telephone Number Area Code FAX Number

4. Date of Birth _____ /_____ /_____ Place of Birth ______________

Month Day Year City State Country

5. Social Security Number __________ ________ _________

I ______ consent _______ do not consent to the use of my Social Security number

for any of the

additional purposes set forth in the Instructions. I understand that

my consent is v

oluntary and that if I do not consent, no adverse action or inference will

be taken or drawn.

6. Ha

ve you previously applied for a New Jersey podiatry license or residency training

permit?

Yes No

If “Yes,” specify and indicate the date submitted:

______________________________ _________________________________

Type Month/Year Type Month/Year

- 1 -

Print Name_____________________________________

First M.I. Last

Section Two - Education

Pre-Podiatry Education

Did you take, pass and receive credit for a minimum of 60 (sixty) post-secondary,

college level or equivalent credits prior to commencing podiatry school OR can you

demonstrate that you have obtained the substan

tial equivalent?

Yes No

List the name and location of every college or university attended where pre-professional,

post-secondary instruction was received:

Name City/State/Country

Dates of Attendance

(From - To)

________________________ ___________________ ___ / ___ - ___ / ___

Podiatry Education

Month Year Month Year Name of Podiatry School(s)

1st year _________ _____ to _______ ______ _________________________

2nd year _________ _____ to _______ ______ _________________________

3rd year _________ _____ to _______ ______ _________________________

4th year _________ _____ to _______ ______ _________________________

Name of institution conferring degree:_________________________________________

Date degree was awarded: _________________

Board Certications

List any certifying board(s) below:

Certication Date Awarded/Expiration Date Board

/

- 2 -

Print Name_____________________________________

First M.I. Last

Section Two - Education (continued)

Endorsement Examinations

National Board of Podiatric Medicine (N.B.P.M.E.) Examination:

Part 1 ___ / ___ / ___

Part 2 ___ / ___ / ___

Sister State: State: ____________ Date ____ / _____

Postgraduate Training

List below each training program (including internship, fellowship) in which you have

participated.

Dates (From - To) Institution

Specialty Credit/No Credit/

Partial Credit

PGY1

___ / ___ - ___ / ___ ____________ ____________ ________________

PGY2

___ / ___ - ___ / ___ ____________ ____________ ________________

PGY3

___ / ___ - ___ / ___ ____________ ____________ ________________

Fellowship

___ / ___ - ___ / ___ ____________ ____________ ________________

Other

___ / ___ - ___ / ___ ____________ ____________ ________________

- 3 -

Month Day Year

Month Year

Month Year Month Year

Print Name_____________________________________

First M.I. Last

Section Three - Employment/Malpractice History/Other Licenses

Privileges/Afliation/Employment/Appointments History

From To Employer/Facility Address

Name:

Street: