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

Fill Online, Printable, Fillable, Blank Memorandum New Jersey Office of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 56 minutes to complete

The Memorandum New Jersey Office of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 20 pages long and contains:

  • 6 signatures
  • 75 check-boxes
  • 164 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Jersey Office of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language Pathology
Advisory Committee
124 Halsey Street, 6 Floor, PO Box 45002, Newark, NJ 07101
th
Memorandum
TO: Applicants for Licensure in Audiology
and/or Speech-Language Pathology
RE: Useful Information for New Jersey Licensure Applicants
“ALERT”
JURISPRUDENCE ORIENTATION FOR AUDIOLOGISTS AND SPEECH LANGUAGE
PATHOLOGISTS
The New Jersey Legislature finds 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 instances when the answer “NOT APPLICABLE” may apply, and 2) it
is a very good idea to make sure you read the entire application before filling 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:
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.
When applying for a Temporary License, make certain that your Supervision
Plan meets the requirements of N.J.A.C. 13:44C-3.5.
When practicing under a Temporary License during your Clinical Internship,
REMEMBER you must complete your Clinical Internship in the time indicated
on your Supervision Plan. For those practicing full-time this is 9 months, for
those practicing part time it may be up to 18 months. PLEASE NOTE THAT
YOUR TEMPORARY LICENSE ENDS WHEN YOU COMPLETE YOUR CLINICAL
INTERNSHIP. You must obtain your permanent license in order to continue to
provide services. The temporary license cannot be renewed.
Any change in supervision, including supervisor, location, or interruption of
supervision must be promptly reported to the Committee’s office.
PRIOR TO COMPLETING YOUR CLINICAL INTERNSHIP, BE SURE PROPER
NOTIFICATION IS MADE TO THIS OFFICE 2 MONTHS BEFORE YOUR
ENDING DATE.
This will allow ample time for processing so there is no lapse of your licensing
between the time your temporary license expires and your permanent license is
processed.
YOU MAY NOT PRACTICE UNDER A TEMPORARY LICENSE BEYOND THE
DATE INDICATED ON YOUR SUPERVISION LETTER.
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) Transcripts
You are required to submit an original transcript bearing the raised seal of the college
or university where you earned your graduate degree.
B) 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.
Should you have questions relating to the application procedure, you may call (973) 504-6390.
Please Note
Once your application process is completed, your temporary license will be processed.
LICENSE NUMBERS WILL NOT BE GIVEN OVER THE PHONE. PLEASE DO NOT CALL THE
OFFICE TO OBTAIN YOUR TEMPORARY LICENSE NUMBER.
New Jersey Office of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language Pathology Advisory Committee
PO Box 45002
Newark, New Jersey 07101
Checklist for Temporary License - Clinical Internship
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.
9 The application is complete. All questions must be answered.
9 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.
9 Original transcripts of grades from the college or university granting you your graduate
degree(s). (School seal must be affixed.)
9 Transcripts of grades in Audiology and/or Speech-Language Pathology for the Praxis
Examination (Administered by the Educational Testing Service). THIS MUST BE
SUBMITTED PRIOR TO PERMANENT LICENSURE.
9 Certification and Authorization Form for a Criminal History Background Check.
9 Completed supervision plan (For temporary license to complete a Clinical Internship
only)
9 Change of name documentation, when applicable.
9 Completed the Jurisprudence Orientation at www.njconsumeraffairs.gov/aud. PUT
THE ADDRESS IN YOUR WEB BROWSER.
FEES: Payable to the State of New Jersey
9 Application fee and temporary fee - $125.00
Please return this completed checklist with your application
New Jersey Office 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
Temporary License Application - Clinical Internship
Check one: Audiology Speech-Language Pathology Audiology Speech-Language Pathology
Date: _______________________________
Please enclose a nonrefundable application ling fee of $75.00 and a temporary license fee of $50.00 (total fee $125.00) 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. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certicate unless you provide the
required documents concerning there plan for payment of your student loan.
6. 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
click to sign
signature
click to edit
7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical 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
those portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity 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
applica
tion. 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 of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded
by statutory law. (N.J.S.A. 45:1-20.)
For the purposes of these questions, the following phrases or words have the following meanings:
“Ability to practice as an audiologist or speech-language pathologist” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of an audiologist or speech-language pathologist, and to learn and
keep abreast of professional developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without the
use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of an audiologist or speech-language pathologist, 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 orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
dia
betes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“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 two years.
“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.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Committee will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to
determine whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you
are not eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
click to sign
signature
click to edit
8. 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.
9. 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
10. 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.)
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
19. 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.
20. 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.
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
__________________________________________________
Name of Notary Public (please print)
Afx Seal Here
__________________________________________________
Signature of Notary Public
click to sign
signature
click to edit
click to sign
signature
click to edit
New Jersey Office of the Attorney General
Division of Consumer Affairs
Audiology and Speech-Language Pathology
Advisory Committee
P.O. Box 45002, Newark, NJ 07101
Supervision Plan
License Sought: G Audiology G Speech-Language Pathology
NOTE: SUPERVISION CANNOT BEGIN UNTIL THE TEMPORARY LICENSE IS ISSUED.
Applicants requiring supervision in Audiology and/or Speech-Language Pathology must
complete a separate Supervision Plan for each.
I. Applicant: (please type or print)
A. Name
Last First Middle Maiden
B. Home
Street Address
City State ZIP Code Home Phone No.
C. New Jersey licensure requirements completed to date or expected completion
date:
Master’s Degree
Month/Year
Internship Year National Examination
Month/Year Month/Year
II. Employment setting in which supervision will take place:
A. Employer
Name Address
City State ZIP Code
Facility
Business Name Street
City State ZIP Code
Is this supervision setting an exempt setting? G Yes G No
B. Hours per week employed in Audiology in Speech-Language Pathology
III. Supervisor
A. Name
B. Home Address
Street Address
City State ZIP Code
C. Employer
Name
Street Address
City State ZIP Code
D. Place of employment
Facility Name
Street Address
City State ZIP Code
E. Telephone Number
Home Work
F. New Jersey license number:
Supervisor’s Affidavit
I, the supervisor, have discussed the following plan with the applicant and accept the
responsibility for its implementation and follow-up, pursuant to N.J.A.C. 13:44C-3.6. I
certify that the foregoing Statements made by me are true. I am aware that if any of the
Statements made by me are willfully false, I am subject to punishment.
Signature of supervisor: Date:
Applicant’s Name:
IV. Supervision Plan
Applicant Activity No. of hours each week No. of hours each month
spent by applicant spent by supervisor
On-site Other monitoring
observation activities
1. Assessment/evaluations
2. Habilitation/rehabilitation
3. In-service training
4. Record Keeping
5. Other (specify)
Total
Applicant’s Affidavit
I, the applicant, have discussed the above plan with my supervisor, and agree to its
implementation and follow through, pursuant to N.J.A.C. 13:44C-3.6. I certify that the
foregoing Statements made by me are true. I am aware that if any of the Statements
made by me are willfully false, I am subject to punishment.
Signature of applicant: Date:
New Jersey Office 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.
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
________________________
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document