Fill - Free fillable Midwifery Liaison Committee Application Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) PDF form

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

State Board of Medical Examiners

Midwifery Liaison Committee

140 East Front Street, 2nd Floor, P.O. Box 183

Trenton, New Jersey 08625

(609) 826-7100

Midwifery Liaison Committee

Application Checklist

Use this checklist to determine whether you have complied with all of the requirements. Once your application has been

received, a le will be established and you will be notied regarding any missing documents or fees.

Three (3) passport-size photographs.

A nonrefundable application fee of $125.00 made payable to the State of New Jersey.

An additional nonrefundable application fee of $50.00 made payable to the State of New Jersey, only if you are also

applying for Prescriptive Authorization.

A copy of your birth certicate, passport or proof of your immigration status.

A completed and notarized application.

Ofcial midwifery education transcripts requested to be sent directly to the Committee at: Midwifery Liaison Committee,

P.O. Box 183, Trenton, New Jersey 08625.

Ofcial verication of your certication status to be sent from one of the following: the American Midwife Certication

Board (A.M.C.B.), the American College of Nurse Midwives Certication Council (A.C.C.), or the North American

Registry of Midwives (N.A.R.M.), as applicable. The form should be sent directly to the Committee at: Midwifery Liaison

Committee, P.O. Box 183, Trenton, New Jersey 08625.

If you are applying for Prescriptive Authorization and have completed your pharmacology education in a program

separate from your midwifery education, an authorized representative of the program should complete the verication

form attached to the application.

A completed and notarized Certication and Authorization Form for a Criminal History Background Check (C.H.B.C.).

Instructions for the completion of a C.H.B.C. will be provided once your application has been received. If you have

been ngerprinted by another New Jersey licensing board (such as the Board of Nursing), please read the instructions

carefully. You do not have to be ngerprinted again. If your ngerprints were completed within the last six months, your

federal background check does not need to be repeated and you should not submit an additional check for $17.50.

Your resume or curriculum vitae.

The Verication of License form sent to the Committee ofce from any and/or all states in which you hold any professional

license. Copies of licenses are not considered adequate verication for this purpose. You may use the attached verication

form or the issuing state may have its own form.

Please take note of the fact that certain responses to some of the questions may require you to submit additional

explanatory information. Please attach any explanations to your application. Please make reference to the number of

the question to which you are responding.

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

State Board of Medical Examiners

Midwifery Liaison Committee

140 East Front Street, 2nd Floor, P.O. Box 183

Trenton, New Jersey 08625

(609) 826-7100

Application for Licensure as a Midwife

Date : ____________________________

I am applying for a license as a:

Certied Nurse Midwife Certied Nurse Midwife with Prescriptive Authority

Certied Professional Midwife Certied Midwife

A nonrefundable application ling fee of $125.00, 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

Place of birth: _______________________

City State Country

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

Apply here one clear, full-face

passport-style photograph

(2˝x 2˝) of your head and

shoulders, taken within the

past six months.

At t a ch t wo ad diti o nal

passport-style photos to this

application.

For ofce use only

Application number:

_____________________

License number:

_____________________

License issue date:

_____________________

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 an American citizen, please enclose a copy of your birth certicate or U.S. passport. 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 unless you provide the

required documents concerning the plan for repayment of your student loan.

6. 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.

___________________________________ ___________________________________ ________________________

Applicant’s name (please print) Applicant’s signature Date

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.)

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

a. The cognitive capacity to exercise the reasonable judgments of a midwife, 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 a midwife, 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.

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

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. Have you served in the Armed Forces of the United States? Yes No

If “Yes,”what type of military discharge did you receive? Indicate the type of discharge you received.

________________________________________________________________________________________________________

12. 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 was issued under a

different name, please provide that name.

_____________________ _______________________ ____________________________ ____________________

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

13. Have you ever taken any other state board or regional board’s exam and failed? Yes No

If “Yes,”please provide the name of the state and the date the exam was taken.

_____________________________________________________ ___________________________________

State Date

14. Have you ever been cited for disciplinary reasons 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

15. 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

16. 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

17. Have you ever been named as a defendant in any litigation related to the practice of midwifery or other professional or

occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?

Yes No

18. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a professional

or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?

Yes No

19. 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

20. 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 midwifery 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 14 through 20, is “Yes,” provide a complete explanation of the

circumstances leading to the action, and any supporting documentation, on separate sheets of paper.

__________________________________________________________________

Last name First name Middle initial

Education

Name and address of institution ____________________________________________________________________________

Name of institution

 _______________________________________________________________________________________________________

Street address City State ZIP code

Date enrolled ___________________________ Completed program on _________________________

An ofcial transcript from a midwifery program accredited by the American College of Nurse Midwives (A.C.N.M.) or

the Midwifery Education Accreditation Council (M.E.A.C.) or their successor organizations, must be forwarded directly

to the Committee’s ofce.

Please submit a resume or curriculum vitae listing all activities including periods of unemployment beginning with

graduation from high school through the present time.

Certication Examinations

Please indicate exam taken: A.C.N.M. / A.M.C.B. A.C.C. N.A.R.M.

Date of certication ____________________________________

An ofcial notarized copy attesting to an applicant’s certied status must be provided by the certication organization

directly to the Committee’s ofce.

Prescriptive Authorization

New Jersey requires that applicants complete their pharmacology education within two years from the date of application (or

as part of your midwifery education), or hold a current prescriptive authorization in another state. If you are not applying for

prescriptive authorization, skip this question and move on to the next.

Do you hold prescriptive authorization in any other state? Yes No

If the answer is “Yes,” the issuing state must submit a Verication of State License form (attached) indicating that the prescriptive

authorization is current and in good standing.

State that issued the license License number Date issued/expired Status

______________________________ _______________________ _____________________ _________________

The verication form must be sent directly from the state(s) to the Midwifery Liaison Committee. In lieu of completing

the attached form, the Committee will accept a state-issued verication letter.

Pharmacology Education

Please complete this section if your pharmacology education was completed in a program other than your midwifery program.

The program must have consisted of at least 30 contact hours and be accredited college or university-based or afliated.

Name and address of institution ____________________________________________________________________________

Name of institution

 _______________________________________________________________________________________________________

Street address City State ZIP code

Date enrolled ___________________________ Completed program on _________________________

AffidAvit

This afdavit is to be executed by the applicant before a notary public:

State of: _____________________________________________

County of:___________________________________________

___________________________________________ , in making this application to the Midwifery Liaison Committee

for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules

of the Midwifery Liaison Committee, swear (or afrm) that I am the applicant and that all 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 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. 45:10-1 et seq., together with the Rules and Regulations of the

Midwifery Liaison Committee, N.J.A.C. 13:35-2A.1 et seq., 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,

agencies 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

_____________________________________________

Name of Notary Public (please print)

_____________________________________________

Signature of Notary Public



} ss.

Afx seal here

AuthorizAtion to releAse records

I, ________________________________________ , hereby authorize all hospitals*, institutions* or organizations, my

references, employers (past and present), and all governmental agencies and instrumentalities (local, state, federal

or foreign) to release to the State Board of Medical Examiners’ Midwifery Liaison Committee any information, les

or records requested by the Board. I further authorize the State Board of Medical Examiners’ Midwifery Liaison

Committee to release to the organizations, individuals and groups listed above any information.

I have carefully read the questions in the foregoing application and have answered them completely without

reservations of any kind, and I declare under penalty to perjury that my answers and all statements made by me

herein are true and correct and further declare that I am the person referred to in the above application. Should I

furnish any false information in this application, I hereby agree that such an act shall constitute cause for denial,

suspension or revocation of my license to practice midwifery in the State of New Jersey.

I have read the above and understand the same.

___________________________________ ______________________________________________

Date Applicant’s name (Please print)

______________________________________________

Applicant’s signature

Sworn and subscribed to before me this ___________

day of _________________________ , ____________

Month Year

_____________________________________________

Name of Notary Public (please print)

_____________________________________________

Signature of Notary Public

*relating to clinical or postgraduate programs

If you require additional space to answer any of the preceding questions, you may attach your response(s) on separate sheets

of paper to the last page of this application, having made sure that you print or type your name and the number of the question

to which you are responding on each of the attachments.

Afx seal here

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

State Board of Medical Examiners

Midwifery Liaison Committee

140 East Front Street, 2nd Floor, P.O. Box 183

Trenton, New Jersey 08625

(609) 826-7100

Verication of State License

A separate form must be used for each state.

(This form may be reproduced.)

Please print clearly.

Name of applicant____________________________________________________________________________________________

Last name First name Middle initial

The above-named applicant is a licensee of the State of __________________________________ and was issued license

number ___________________________________ on ________________________________________ .

Month / Day / Year

The applicant was licensed by:

Examination

Endorsement / Reciprocity from the State of _____________________________ .

The license status is:

Current and in good standing expiring on _____________________ . Revoked or Suspended

Date

Inactive / Expired on _______________________ . Other (Please attach an explanation.)

Date

This licensee does does not hold prescriptive authority in this State.

This licensee does does not have a record of disciplinary history with this agency.

(Attach additional information if applicable.)

Certication

I hereby certify that to the best of my knowledge and belief, the foregoing is a true statement of the record of the individual

named on this form.

___________________________________ __________________________________________

Date Name of Board

__________________________________________

Name of person completing this form

__________________________________________

Title

_____________________________________________________________

Signature

Afx Board

seal here

         

New Jersey Ofﬁce of the Attorney General

Division of Consumer Affairs

State Board of Medical Examiners

Midwifery Liaison Committee

P.O. Box 46018

Newark, New Jersey 07101

(973) 273-8009

CertifiCation and authorization form

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

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

State Board of Medical Examiners

Midwifery Liaison Committee

140 East Front Street, 2nd Floor, P.O. Box 183

Trenton, New Jersey 08625

(609) 826-7100

Verication of Pharmacology Education

Please print clearly.

Name of applicant____________________________________________________________________________________________

Last name First name Middle initial

Course title __________________________________________________________________________________________________

Address _____________________________________________________________________________________________________

Street address City State ZIP code

Hours completed _____________________ Dates _____________________________________

It is hereby certied that the above-named Certied Nurse Midwife has successfully completed a minimum educational program

of at least 30 contact hours, as dened by the National Task Force on the Continuing Education Unit, in the course identied

above on the date shown. This individual received full credit from the organization for the course shown.

___________________________________ __________________________________________

Date Signature

__________________________________________

Title of certifying ofcial

Note

This form must reect the seal of the organization sponsoring the course. A copy of the course’s syllabus must be attached to

the form unless the course has been previously approved by the Committee.

Return this form to the address noted above.

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Midwifery Liaison Committee Application Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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