Fillable Licensing Requirements for Electrologist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Licensing Requirements for Electrologist (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 Medical Examiners
Electrologists Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
Licensing Requirements for Electrologist
To be eligible for licensure as an electrologist, an applicant shall fulll the requirements cited below pursuant to N.J.S.A. 45:9-37.83.
• Must be at least 18 years of age
• Be of good moral character
• Provide proof of successful completion of high school or its equivalent; Copy of the actual diploma, high school
equivalent diploma/GED is acceptable or high school transcript that shows the date of graduation is acceptable. If the
transcript is in a language other than English, an ofcial translation of the foreign document; this must be done by a
qualied individual who can attest to its accuracy.
An applicant from a foreign country shall request the high school or the department of education of the country of origin
to send proof of successful completion of high school directly to the Electrologists Advisory Committee (EAC). If the
document is in a language other than English, then please provide an ofcial translation of the foreign document; this must be
done by a qualied individual who can attest to its accuracy. Further, the applicant is required to proof its equivalency
from an authorized credentialing agency.
• Provide proof of successful completion of an approved EAC electrology education program and taught by an
electrology instructor licensed of 200 hours of instruction in the theory of electrology and 400 hours of instruction
in the clinical practice of electrology. Ofcial transcript must be sent directly from an approved electrology education
program. If the electrology education program is completed in another state an electrology education program, please
provide a curriculum outline and a letter from the director of the education program for the EAC to determine whether the
program is substantially equivalent.
• Provide proof of having successfully completed and passed the New Jersey Electrology Jurisprudence Examination.
* To become eligible to sit for the examination, the applicant must submit his/her application and applicable fees to the
Electrologists Advisory Committee. For a current schedule of upcoming exams, as well as current exam information,
please contact the Electrologists Advisory Committee at 973-504-6377.
• Provide proof of having successfully completed and passed the International Board of Electrologists Certication (IBEC)
examination which is administered by the American Electrology Association (AEA).
To become eligible to sit for the IBEC examination, the applicant must have successfully passed the New Jersey Electrology
Jurisprudence Examination. Thereafter, upon completion of the application review process, the EAC will inform approved
candidates, by letter, that they may sit for the IBEC examination.
Candidates should thereafter expect to receive both authorization from the AEA testing vendor to sit for the IBEC examination
and information regarding the registration process. Candidates will be responsible for paying the required $153.00 examination
fee directly to the testing vendor by credit card at the time they register and schedule their exam.
• Successfully passing a Criminal Background Check.
- 1 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Electrologists Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
Application for Licensure as an Electrologist
Date: _____________________________
A nonrefundable application ling fee of $100 in the form of a check or money order made out to the State of New Jersey, must be
submitted with this application. (Applicants should understand that if the application ling 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 licensure or certication 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
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
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
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photograph is required with
each application.
Do not use staples to attach the
photograph.
- 2 -
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal 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 or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records;
b. the Probation Division or any other agency responsible for child support enforcement, upon request; and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support (You must answer a, b, c and d.)
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial 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.
- 3 -
6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous substances. Please read the denitions carefully. Your responses
will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer this question if
you have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you
may assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in
good faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on
the application. Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against
self-incrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that
you have refused to answer on the basis on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
365 days, whichever is longer.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
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- 4 -
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 finding 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 or occupational 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
11. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever had a professional or occupational 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 or occupational
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 electrology or other professional or occupational
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 or occupational 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 or
occupational group related to the practice of electrology or other professional or occupational 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.
Licensing requirements for an electrologist.
Please review N.J.A.C. 13:35-12.6
1. Are you at least 18 years of age? Yes No
2. Have you completed high school or its equivalent? Yes No
If “Yes,” you must submit an ofcial transcript.
3. Have you successfully completed:
An electrology education program accredited by the Council on Accreditation of Electrology Educational Institutions/Programs of
the American Electrology Association, or its successor, which includes at least 200 hours of instruction in the theory of electrology
and at least 400 hours of instruction in the clinical practice of electrology? Yes No
If “Yes,” you must submit a copy of the certicate of completion.
4. Have you passed the Certied Professional Electrology examination? Yes No
- 5 -
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the Electrologists Advisory
Committee for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules
of the Electrologists Advisory Committee, swear (or afrm) that I am the applicant and that all information provided in con-
nection 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 licensure or certication or to withhold renewal of or
suspend or revoke a license or certicate issued by the Committee.
I further swear (or afrm) that I have read N.J.S.A. 45:9-37.76 et seq., together with the Rules and Regulations of the
Electrologists Advisory Committee, N.J.A.C. 13:35-12, and fully understand that in receiving licensure or
certication from the Committee, I bind myself to be governed by them.
Furthermore, 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 licensure or certication. I further authorize all institutions, employers, agen-
cies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or
records requested by the Committee.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
Afx Seal Here
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
For ofce use
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- 6 -
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Electrologists Advisory Committee
P.O. Box 45041
Newark, New Jersey 07101
(973) 504-6377
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.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
- 7 -
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________
_________________________________
Signature of applicant Date
Rev. 1/2/19
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Licensing Requirements for Electrologist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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