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: Applicants for Licensure in Audiology and/or Speech-Language Pathology
FROM: Renee P. Clark, Executive Director
RE: Useful Information for New Jersey Licensure Applicants
“ALERT”
JURISPRUDENCE ORIENTATION FOR AUDIOLOGISTS AND SPEECH LANGUAGE PATHOLOGISTS
The New Jersey Legislature nds and declares that the practice of audiology and speech language pathology
needs to be regulated for the protection of the health, safety and welfare of the citizens of this State. In order
to raise awareness of current New Jersey statutes and regulations applicable to the practice of audiology and
speech language pathology, it is now required that all new applicants for licensure (13:44C-3.2(c); applicants
who are licensed in other states who wish to become licensed in New Jersey (13:44C-3.4(d); individuals apply for
temporary licenses (13:44C-5.2(c) and current licensees who are renewing their license as part of their biennial
license renewal and reinstatement (13:44C-4.1(i), complete an online Jurisprudence Orientation.
Please note that 1) under the medical conditions section of the application (question number 7), there are in-
stances when the answer “NOT APPLICABLE” may apply, and 2) it is a very good idea to make sure you read
the entire application before lling it out.
Please follow the instructions carefully and remember that full compliance is necessary before you will be issued a
license and can begin work.
To assist you, we have listed some common pitfalls which delay processing:
• The New Jersey Audiology and Speech-Language Pathology Advisory Committee will not verify your
professional status with the American Speech-Language Hearing Association (ASHA). You must contact
ASHA and request your certication or credentials.
• For your convenience, please be advised that our Reporting Code Number for your PRAXIS score is R7668.
Use of this number when requesting transmission will facilitate processing.
FINALLY
Do not confuse the New Jersey Audiology and Speech-Language Pathology Advisory Committee with ASHA.
The fact that ASHA is in receipt of your records does not satisfy your obligation to the State of New Jersey.
A) Examination Scores
The law stipulates that all holders of a New Jersey license for Audiology or Speech- Language Pathology show
evidence of having passed the Praxis Examination which is administered by the Educational Testing Service
(E.T.S.). Since E.T.S. has a policy of keeping scores for only ve (5) years, the Committee will accept an original
or notarized copy of your Certicate of Clinical Competence as satisfactory proof of having passed the Praxis
examination in lieu of the actual score.
B) Transcripts
You are required to submit an original transcript bearing the raised seal of the college or university where you
earned your graduate degree.
C) Continuing Professional Education
Your license to practice Audiology or Speech-Language Pathology in the State of New Jersey must be renewed
every two years. Pursuant to N.J.A.C. 13:44C-6.2(b) Licensees applying for their rst biennial renewal are exempt
from the continuing education requirements.
D) Jurisprudence Orientation
You must go to www.njconsumeraffairs.gov/aud, to complete the Jurisprudence Orientation that is now required.
PUT THE ADDRESS IN YOUR WEB BROWSER.
E) If you have been licensed in another state, be sure to forward verication of your license in to the Committee.
Should you have questions relating to the application procedure, you may call (973) 504-6390.
Please Note
Once your application process is completed, your permanent license will be processed. LICENSE NUMBERS
WILL NOT BE GIVEN OVER THE PHONE. PLEASE DO NOT CALL THE OFFICE TO OBTAIN YOUR
PERMANENT LICENSE NUMBER.
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
Checklist for Audiologist and/or Speech-Language Pathologist
Important: Do not send in partially completed applications, they will be returned. To facilitate the processing of your
application, without delay, please be sure you have complied with this checklist and instructions.
The application is complete. All questions must be answered.
Two (2) passport size photos are included. The photos should be of your head and shoulders only and be
(2” x 2”), taken within the past six months.
Original transcripts of grades from the college or university granting you your graduate degree(s). (School seal
must be afxed.)
An original or notarized copy of a statement by your supervisor stating that you have successfully completed
your Clinical Internship. An original or notarized copy of a “CCC” will be acceptable documentation for those
persons who completed their Clinical internship more than a year ago.
Transcripts of grades in Audiology and/or Speech-Language Pathology for the Praxis Examination (Administered
by the Educational Testing Service). An original or notarized copy of a “CCC” will be acceptable documentation
for those persons who completed their PRAXIS more than ve years ago.
Certication and Authorization Form for a Criminal History Background Check.
Change of name documentation, when applicable.
Completed the Jurisprudence Orientation at www.njconsumeraffairs.gov/aud. PUT THE ADDRESS IN
YOUR WEB BROWSER.
If you are licensed in another state, send verication of license directly from that State.
FEES: Payable to the State of New Jersey
Application fee and license fee - $245.00
Application fee and license fee - $160.00 (Second half of the biennial licensing period commencing odd
years (11/1 to 10/31)
NOTE: PLEASE CHECK WITH THE COMMITTEE REGARDING WHICH FEE TO SEND BEFORE
SUBMITTING YOUR APPLICATION.
Please return this completed checklist with your application
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
License Application
Check one: Audiology Speech-Language Pathology Audiology Speech-Language Pathology
Date: _______________________________
Please enclose a nonrefundable application ling fee of $75.00 and an initial license fee of $170.00 (total fee $245.00) in the
form of a check or money order made out to the State of New Jersey. (Applicants should understand that if the fees
are 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 fees are paid.)
The Committee maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You
may choose which of these addresses will be considered as your “address of record.” If you do not indicate (by putting a check in the
appropriate box) which address should be used as your address of record, your mailing address will be considered to be your address of
record. A post ofce box may be used as your address of record, but only if you provide another address which includes 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.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State
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
Photo #1
Photo #2
Attach two clear, full-face pass-
port-style photographs (2˝x 2˝)
of your head and shoulders, taken
within the past six months.
Two photographs are required
with each application.
Do not use staples to attach the
photographs.
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
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.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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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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signature
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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, certicate or permit 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, certicate or permit 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, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
_____________________ _______________________ ________________________________ __________________
Type of license, certicate or permit Number State or jurisdiction that issued the license, certicate or permit Date issued/expired
11. Have you ever been disciplined or denied a professional license, certicate or permit 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 license, certicate or permit 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 any prior practice as an audiologist or speech-language pathologist, 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, certicate or permit 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 any prior practice as an audiologist or speech-language pathologist, 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.
18. List the school(s) from which you obtained a master’s degree or a bachelor’s degree and 42 post-baccalaureate semester hours in
audiology, speech-language pathology or both:
Name of School Major Dates Attended Degree
1.) _____________________________________________________________________________________________________
2.) _____________________________________________________________________________________________________
3.) _____________________________________________________________________________________________________
4.) _____________________________________________________________________________________________________
Arrange for the school(s) from which you obtained a master’s degree or a bachelor’s degree and 42 post-baccalaureate semester hours
in audiology, speech-language pathology or both to forward a transcript directly to the Audiology and Speech-Language Pathology
Advisory Committee.
19. List the schools at which you completed 75 hours of academic credit and 350 hours of supervised clinical experience pursuant
to N.J.A.C. 13:44C-3.3.
Name of School Dates Attended
1.) _____________________________________________________________________________________________________
2.) _____________________________________________________________________________________________________
3.) _____________________________________________________________________________________________________
4.) _____________________________________________________________________________________________________
Arrange for the school(s) at which you completed the hours of academic credit and supervised clinical experience to forward proof
of completion directly to the Audiology and Speech-Language Pathology Advisory Committee.
20. National Teachers Examination (N.T.E.) in audiology and/or speech-language pathology
Area ____________ Score __________ Area ___________ Score _____________ Date passed _________________________
An original copy of the Praxis score reporting form is required. A notarized copy of a Certicate of Clinical Competence
(C.C.C.) will be acceptable only if the National Examination was taken more than 5 years ago.
21. Is your supervision plan on le with the ofce of the Advisory Committee on Audiology and Speech-Language Pathology?
Yes No
If “No,” please explain below:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
22. Where was your internship completed? ________________________________________________________________________
23. Name of supervisor _________________________________________________________ State _________________________
License number of supervisor _________________________________ Date internship commenced _______________________
Date internship completed ____________________________
An original or notarized copy of a statement by your supervisor stating that you have successfully completed your internship
is required. A notarized copy of a C.C.C. will be acceptable documentation for those applicants who completed internships
more than one year ago.
Waiver
I hereby authorize all institutions, my references, employers past and present, business and professional associations, and all private,
personnel and government agencies or instrumentalities (local, state, federal and foreign) to release to the Audiology and Speech-Language
Pathology Advisory Committee, any information which is material to my application.
I have carefully read the questions in this application and have answered them completely, without reservations of any kind, and declare
under penalty of perjury that my answers and all statements made by me herein are true and correct and that I am the person referred to
in this application.
Should I intentionally furnish any false information in this application, I hereby agree that such acts shall constitute cause for denial,
suspension or revocation of my license to practice as an Audiologist and/or Speech-Language Pathologist in the State of New Jersey.
I have read the above and understand the same.
__________________________________________________
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
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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
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 con-
ducted 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
________________________
CCertifi ation
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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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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