Fillable MEMORANDUM New Jersey Ofce of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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MEMORANDUM New Jersey Ofce of the Attorney General (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
Audiology and Speech-Language
Pathology Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45002
Newark, New Jersey 07101
(973) 504-6390
MEMORANDUM
To: Name
Address
Address
From:
Date:
Re: InactivetoActiceStatus41YS00XXXXXXXX
**********************************************************************************
1. 20CEU’sfor(BiennialPeriod11/1/17to10/31/19)
20CEU’sRequired
Note:IfyouareregisteredwithASHAyoumustsubmityourofcialASHAtranscript
alongwithcopiesofyourcerticates
2. ApplicationtoReactivateanInactiveLicense(enclosed).
3. LicenseVericationfromanotherstateifapplicable.
4. TheenclosedCEtracker.
5. PaymentoftheRenewalFee(s):
11/1/17-10/31/19$170.00
6. ResubmitCriminalHistory
BackgroundCheckFee:$18.75
Total:$188.75Required(MadepayabletotheStateofNewJersey.)
Pleasebeinformedyoumaycomplete10CEU’sonline.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language
Pathology Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45002
Newark, New Jersey 07101
(973) 504-6390
ApplicationtoReactivateanInactiveLicense
N.J.LicenseNo.:______________________________________TypeofLicense:_______________________________________
InitialLicenseDate:________________________________DateLicenseBecameInactive:_____________________________
Please submit with this application a check or money order for $170.00 made out 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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ourdirectories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 (including youraddress of record) 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.
SectionI
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
3. *SocialSecurityNo:____-____-____
YoumustprovideyourSocialSecuritynumbertotheCommittee.Failuretodosowillresultindenialoflicensureorcertication
reinstatement.
*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Committee
isrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,the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limitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedby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
Questionsabout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 will result in a denial of
reinstatement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
6. 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.
7. Haveyoueverbeensummoned;arrested;takenintocustody;indicted;tried;chargedwith;admittedintopre-trialintervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
8. 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.)
9. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykind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/expire
10. Haveyoueverbeendisciplinedordenied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
11. 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
12. 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
13. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofaudiology/speech-languagepathologyorother
professionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
  Yes No
14. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
15. 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
1. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
relatedtothepracticeofaudiology/speech-languagepathology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10through16,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
Note:Inordertoreturntoactivestatus,youmustsubmitwiththisapplicationproofthatyouhavecompletedthecontinuing
educationhoursorcreditsrequiredforeachbiennialperiodthatyourlicensewasininactivestatus.
ContinuingEducation
Pleaselistallofthecoursesthatyouhavesuccessfullycompletedsinceyourlicensebecameinactive.
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.

_____________________________________________________ ____________________________________
SignatureofapplicantDate

click to sign
signature
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CertifiCation for reaCtivation appliCation
I, ________________________________________________ , in making this application to the Committee for reactivation
of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reactivationortowithholdrenewaloforsuspendorrevokealicenseissuedbythe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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Committee.
Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare
willfullyfalse,Iamsubjecttopunishment.
_____________________________________________________________ ___________________________________

SignatureofapplicantDate
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signature
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language
Pathology Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45002
Newark, New Jersey 07101
(973) 504-6390
EmploymentCerticationfortheReactivationofaLicense
Directions: Please complete this certication. Sign and date it and then return it to the Audiology and Speech-
Language Pathology Advisory Committee.Ifyouhavehadmorethanthreeemployers,pleaseattachadditionalsheets
ofpapertothiscerticationwiththeemploymentdata.TheCommitteemaycontactyouremployer(s)toverifyyour
employment.
Pleaseprintclearly.
__________________________________________________________________________________________________
Firstname Middlename Lastname Maidenname
__________________________________________________________________________________________________
PresentStreetAddress City State ZIPCode
N.J.LicenseNo.___________________________
EmploymentData:
Areyoucurrentlyworkingasanaudiologistandspeech-languagepathologist,ordidyouworkasanaudiologistand
speech-languagepathologistwhileyourlicensewasininactivestatus?
Yes No
1. ______________________________________________________________________________________________
Nameofemployingagencyorfacility
______________________________________________________________________________________________
Streetaddress
______________________________________________________________________________________________
City State ZIPCode
______________________________________________________________________________________________
JobTitle EmploymentDates:FromTo
______________________________________________________________________________________________
Supervisor’sname Title TelephoneNo.(includeareacode)
2. ______________________________________________________________________________________________
Nameofemployingagencyorfacility
______________________________________________________________________________________________
Streetaddress
______________________________________________________________________________________________
City State ZIPCode
______________________________________________________________________________________________
JobTitle EmploymentDates:FromTo
______________________________________________________________________________________________
Supervisor’sname Title TelephoneNo.(includeareacode)
3. ______________________________________________________________________________________________
Nameofemployingagencyorfacility
______________________________________________________________________________________________
Streetaddress
______________________________________________________________________________________________
City State ZIPCode
______________________________________________________________________________________________
JobTitle EmploymentDates:FromTo
______________________________________________________________________________________________
Supervisor’sname Title TelephoneNo.(includeareacode)
_______________________________________________________________________________________________________
Applicant’sname(Pleaseprint) Applicant’ssignature Date
click to sign
signature
click to edit
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language Pathology
P.O. Box 45002
Newark, New Jersey 07101
(973) 504-6390
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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.
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
________________________
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
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language
Pathology Advisory Committee
124 Halsey Street, 6th Floor, P.O. Box 45002
Newark, New Jersey 07101
(973) 504-6390
ContinuingEducationTracker
RenewalPeriod-11/1/15to10/31/17
• Continuingeducationcreditsmustbecompletedduringtherenewalperiod.
• Completethisformandreturnwithsupportingdocumentation.
• RefertoN.J.A.C.13:44c-6.2(AllocationofCredits)andN.J.A.C.13:44c-6.3(DocumentationofContinuingEducation
 Credtis).
IcertifythattheinformationprovidedisaccurateandIamattachingsupportingdocumentation.
____________________________________________________________________________________________
SignatureofLicensee N.J.LicenseNumber
Thisformcanbeduplicatedtoincludeadditionalcourseinformation-incompleteformswillbereturned.
Date(s)
Completed
CourseName
(Refertoregulationforapproved
sponsorinformation)
Number
ofHours
(A)In-Person
(B)Online
 Self-Study
Pleaseputa
(✓) check
Pleaseputa
(✓) check
(C) Online
Interactive
Webinar
Pleaseputa
(✓) check
Denied
Numberof
Hours
(InternalUse
Only)
TOTALPERCOLUMN
TotalColumn(A)
TotalColumn(B)
Max#10Hrs.
TotalColumn(C)
Max#10Hrs.
TotalColumn
(A),(B),(C)
Total
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MEMORANDUM New Jersey Ofce of the Attorney General (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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