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NEW JERSEY OFFICE OF THE ATTORNEY GENERAL DIVISION (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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NEW JERSEY OFFICE OF THE ATTORNEY GENERAL
DIVISION OF CONSUMER AFFAIRS
OCCUPATIONAL THERAPY ADVISORY COUNCIL
INSTRUCTIONS FOR REINSTATING/RE-ACTIVATION
In accordance with the Uniform Enforcement Act, a professional or occupational license may be
reinstated, provided that the applicant otherwise qualifies for licensure, and complies with the
provisions of N.J.S.A.45: 1-7.2(a),(b),(c)and (d). The necessary application and materials for
applying for reinstatement and /or re-activation are enclosed.
1. Complete: The enclosed application for reinstatement. attached to the documentation/fees
listed below.
2. Submit the following documentation and fees accordingly to your category:
* Biennial Renewal Period (2015-2017) :
Occupational Therapist $ 160.00.
Occupational Therapy Assistant $ 100.00.
* Payment of a reinstatement fee; * (The reinstatement fee is $80.00 for both an
Occupational Therapist and Occupational Therapy Assistant)
* An affidavit of employment listing each job held during the lapsed licensure period.
This affidavit of employment must include the names, addresses and telephone
numbers of each employer;
* “A notarized statement indicating if you were or were not engaged in the practice
of your profession or occupation in New Jersey during the period that your New
Jersey license was lapsed. If you were practicing your profession or occupation
during this lapsed license period, you must include a description of the type of work
or projects that you were involved with” , and
* Completion of Criminal History Background Check.
See enclosed instructions and form to be completed .
3) Submit to: New Jersey Office of the Attorney General
Division of Consumer Affairs
Occupational Therapy Advisory Council
PO Box 45037
Newark, NJ 07101
Upon review and approval of your reinstatement application, a license will be issued.
New Jersey Office of the Attorney General
DIVISION OF CONSUMER AFFAIRS
OCCUPATIONAL THERAPY ADVISORY COUNCIL
APPLICATION FOR REINSTATEMENT/REACTIVATION OF NEW JERSEY LICENSE
YOU MAY NOT PRACTICE IN THE STATE OF NEW JERSEY UNTIL YOUR LICENSE OR
CERTIFICATE IS REINSTATED.
The Council maintains, as part of its responsibilities, a record of your home address, business address and
mailing address. You may choose which one of these addresses will be considered your “address of record”
subject to public disclosure. If you do not indicate (by putting a check in the appropriate box) which address
should be used as your address of record, your ma iling address will be consider ed to be your address of
record. A post office 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.
NOTE: The Division is precluded by law from disclosing to the public the place of residence of its
licensees without their consent. If you provide your place of residence as your public address of
record, we assume you have consented to its disclosuree. If you wish to use a different address as your
address of record, please notify the Council of the preferred address. Note further that the Council will
address correspondence to your mailing address. You are reminded, therefore, to keep the Council
apprised of your current mailing address at all times. This will assure that future renewal materials and
other important correspondence from the Council regarding professional practice will reach you in a
timely manner.
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. The application must
be notarized and accompanied by the enclosures noted on the instruction sheet and the total fee noted on
the enclosed invoice.
Personal Information:
9 Mr. 9 Mrs. 9 Ms.
Name_________________________________________________________________________
Address Information
9 Home_______________________________________________________________________
City, State, Zip _________________________________________________________________
Telephone Number____________________ E-mail address__________________
Include area code (Indicate NA if you do not have an e-mail address.)
9 Business_____________________________________________________________________
City, State, Zip _________________________________________________________________
Telephone Number____________________ E-mail address__________________
Include area code (Indicate NA if you do not have an e-mail address.)
9 Mailing_____________________________________________________________________
City, State, Zip _________________________________________________________________
Type of License/Certificate___________________ NJ License/Certificate Number___________
Initial License/Certificate Date___________________ Date of Last Renewal_____________
Answer all questions from the time period that you were last licensed in New Jersey.
1.Have you been arrested, charged or convicted of any crime or offense that you have not already reported
to your board/committee? (Minor traffic offenses, such as speeding or parking need not be provided but
Motor Vehicle offenses such as driving while impaired or intoxicated must be disclosed.)
9Yes 9No
2.Has any action been taken or is any action now pending against your professional license or have you been
permitted to surrender or otherwise relinquish your license to avoid inquiry, investigation or action by any other
licensing authority that you have not already reported to your board/committee?
9Yes 9No
AFFIDAVIT OF APPLICANT
I,_________________________________, being duly sworn, depose and say under penalty of false statement,
I am the person described and identified in this application; that the information given in this application and
all submitted materials contain no willful misrepresentations and that the information is true and complete. I
understand that should an investigation at any time disclose otherwise, my application may be rejected, and
I may face legal sanctions if I am already licens ed. I under stand t hat in si gning this application for
reinstatement, I am consenting to any reasonable inquiry that may be necessary to verify the information I have
provided on this form or may provide in conjunction with this application.
_____________________________________ ______________________________
Applicant’s Full Signature Date
____________________________________ ______________________________
Notary’s Full Signature Date
Notary’s Commission Expires On:_______________
New Jersey Office of the Attorney General
Division of Consumer Affairs
Occupational Therapy Advisory Council
P.O. Box 45037
Newark, New Jersey 07101
(973) 504-6570
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
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NEW JERSEY OFFICE OF THE ATTORNEY GENERAL DIVISION (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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