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NJ DEPARTMENT OF BANKING AND INSURANCE LICENSING SERVICES (State of New Jersey)

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NJ DEPARTMENT OF BANKING AND INSURANCE
LICENSING SERVICES BUREAU
P.O. BOX 473
TRENTON, NJ 08625
LICENSE APPLICATION INSTRUCTIONS
NEW JERSEY IN-STATE OFFICE LOCATION REQUIRED
All applications submitted to this office must be complete and include all fees, documents/
attachments. A preliminary review for correct fees will occur upon submission. No further
review will occur if the fees are incorrect. Any incomplete application will not be accepted
for processing and will be returned in its entirety. The processing time is contingent upon
the complexity of the application.
GENERAL INSTRUCTIONS
1. If your business entity is not providing financing, this license is not required.
2. Type or print clearly all answers. Do not leave any questions unanswered. If a question is
not applicable or the answer is none, please type or print N/A or NONE.
3. Insert on line #1, the complete name of the corporation, limited liability company,
partnership, or sole proprietorship exactly as it appears in your incorporation/formation
papers as filed with the N J Division of Revenue or on your trade name certificate filed with
your County Clerk’s office.
4. If you are unable to receive mail at the proposed address to be licensed appearing on the
application, provide an alternate mailing address.
5. Attach a copy of your Certificate of Incorporation/Formation bearing the dated filing stamp
of the Treasurer of the State of New Jersey. Foreign (out-of-state) entities must attach a copy
of the Certificate of Authority to do Business in New Jersey bearing the dated filing stamp of
the Treasurer of the State of New Jersey. A limited liability company must submit a copy of
the LLC operating agreement. Partnerships or sole proprietorships utilizing a trade name
must attach a copy of the trade name certificate bearing the dated filing stamp of the County
Clerk’s office in the county in which their business is to be located.
6. Attach a copy of the registration of alternate/fictitious name bearing the dated filing stamp of
the Treasurer of the State of New Jersey if the entity uses a “doing business as/alternate
name”. If such name is used, it must be included on the line provided for D/B/A or Trade
Name.
7. Application must be properly signed and dated by: (1) corporate president and secretary if a
corporation; (2) managing member and witness if a limited liability company; (3) member of
the partnership and a witness if a partnership; or (4) the sole proprietor and a witness if a sole
proprietorship, in the spaces provided for attestation. Corporate seal or a facsimile of same
must be affixed in the case of a corporate applicant. Signatures must be witnessed by a
notary public or attorney.
HRCINST072015
8. Personal Certifications must be completed by all officers, directors, substantial stockholders
(10% or more), members, partners or owners.
9. All applicants must attach a financial statement as prepared by your accountant/office
manager/bookkeeper demonstrating net worth. In the instance of a newly formed company,
attach a start-up balance sheet.
10. PROPERTY DOCUMENTATION: Attach a copy of deed, lease or rental agreement for
location to be licensed as listed on the application. You must also submit two (2) photographs
of the office location- one exterior and one interior. One (1) photograph must clearly show
the required business sign.
11. RESIDENCE: If you conduct business from a residence, you must attach copies of letters you
have sent to your local post office and telephone company advising them of the use of your
re
sidence for your business. You must also submit a copy of the deed, lease or rental agreement
for the residence.
12. INSURANCE: Submit copy of Certificate of Insurance showing that you have public liability
and worker’s compensation insurance. The certificate should show the New Jersey Department
of Banking and Insurance at the address on the top of the application as a party of interest. The
certificate should also show your agent’s name, address and telephone number.
13. CONSUMER AFFAIRS REGISTRATION: Submit proof of Home Improvement Contractor
registration with the New Jersey Division of Consumer Affairs. You can obtain information
re
garding the Home Improvement Contractor registration by calling 1-888-656-6225 or at
www.nj.gov/oag/ca/HIC/.
14. Submit a $300 company check or money order made payable to: Treasurer, State of New
Jersey. Personal checks are not accepted. NOTE:
All fees submitted with an application
are NON-REFUNDABLE.
NOTE: If you employ salespersons to execute home repair contracts with homeowners on behalf
of your company, you must license each individual so employed. Officers of the corporation are
not required to be licensed as a home repair salesperson.
Questions regarding an application may be directed to (609) 292-7272 – follow the prompts and
select option #3, then select option #2, and then select option #1 to be connected to Banking
Licensing.
Send by regular mail to: or for Overnight Mail Service send to:
Licensing Services Bureau Licensing Services Bureau
N.J. Dept. of Banking & Insurance N.J. Dept. of Banking & Insurance
PO Box 473 20 W. State St. – 8
th
Floor
Trenton, NJ 08625 Trenton, NJ 08608
HRCINST072015
DEPARTMENT USE ONLY:
Ref No. Rel No. C/R No. Date Proc.
STATE OF NEW JERSEY
DEPARTMENT OF BANKING and INSURANCE
LI
CENSING SERVICES BUREAU
PO Box 473
Trenton, NJ 08625
HOME REPAIR CONTRACTOR
BUSINESS ENTITY APPLICATION
NEW JERSEY IN-STATE OFFICE LOCATION REQUIRED
DOES THE COMPANY PLAN TO OFFER FINANCE OPTIONS TO
CONSUMERS OVER A PERIOD GREATER THAN 90 DAYS? YES NO
PLEASE NOTE ALL HOME REPAIR CONTRACTORS, REGARDLESS OF PAYMENT
METHOD, MUST ALSO CONTACT NJ DIVISION OF CONSUMER AFFAIRS
CONCERNING REQUIRED REGISTRATION. YOU CAN OBTAIN INFORMATION BY
CALLING 1-888-656-6225 OR AT www.njconsumeraffairs.gov/hic/Pages/default.aspx.
THIS APPLICATION IS FILED BY A: Corporation Sole Proprietor Partnership
Limited Partnership Limited Liability Company
TYPE OR PRINT CLEARLY
1. Name of applicant:_____________________________________________________________________
D/B/A or Trade Name (if applicable)_______________________________________________________
2. N.J. Principal Business Address:
(include County)_______________________________________________
_____________________________________________________________________________________
Contact Person___________________________________________ Tel. No._______________________
E-mail address
(Required)_________________________________________________________________
3. Federal Tax Identification No._____________________________________________________________
4. Alternate mailing address, if different from address to be licensed:
_____
___________________________________________________________________
Address
_____
___________________________________________________________________
Person to Contact Telephone No.
5. Officer/Member/Partner/Sole Proprietor information (attach additional sheets if necessary):
NAME
TITLE
BUSINESS ADDRESS
6. D
irector information (attach additional sheets if necessary):
BUSINESS ADDRESS
7. S
tockholder/Member information (owners of more than 10%). Attach additional sheets if necessary.
NAME
% of
OWNER-
SHIP
BUSINESS ADDRESS
8. Name and business address of the registered agent in this State ____________________________________
_______________________________________________________________________________________
9. Date of incorporation/formation: ____________________________________________________________
10. P
lace of incorporation/formation: _____________________in the County of ____________State of ______
11. A
pplicable to foreign entities: Date of authorization to do business in New Jersey _______________
Attach certified copy of certificate of incorporation/formation with all amendments to date.
12. A
re all of the officers, members, directors, partners, owners or substantial stockholders over 18 years of
age? Yes___ No___. Are all of the officers, members, directors, partners, owners or substantial
stockholders citizens of the United States? Yes _____ N
o _____.
13. I
s the applicant or any officer, member, director, partner, owner or substantial stockholder now under
investigation in this state, any other state, or federal jurisdiction? Yes _____ No _____
14. H
as the applicant or any officer, member, director, partner, owner or substantial stockholder had any fines
or penalties levied in this state, any other state, or federal jurisdiction? Yes _____ No _____
2
15. Has the applicant or any officer, member, director, partner, owner or substantial stockholder been arrested,
indicted, convicted or pleaded “nolo contendere” to any offense, crime or misdemeanor (other than a motor
vehicle violation) in this state, any other state, or by the federal government? Yes ____ No _____
If “yes”,
complete an ARREST FORM found on www.dobi.nj.gov.
16. Has the applicant or any officer, member, director, partner, owner or substantial stockholder ever had a
license, or right to engage in any other business or profession, revoked, denied, suspended, restrained by any
agency of this state, any other state, or by the federal government? Yes _____ No _____
17. Has the applicant or any officer, member, director, partner, owner or substantial stockholder of your
organization ever held any license issued by the Department of Banking and Insurance?
Yes _____ No _____.
18. Has the applicant or any officer, member, director, partner, owner or substantial stockholder ever filed a
petition in bankruptcy or reorganization or been affiliated with any entity that has filed a petition in
bankruptcy or reorganization? Yes _____ No _____.
19. Has the applicant or any officer, member, director, partner, owner or substantial stockholder been involved
in material litigation during the five years prior to application? Yes ____No ____. Material litigation
means any litigation that, according to generally accepted accounting principles, is deemed significant to
any applicant’s or licensee’s financial health and would be required to be referenced in that entity’s annual
audited financial statements, reports to shareholders or similar documents.
SOLE PROPRIETOR ONLY
20. Are you the subject of an arrest warrant for failing to comply with court ordered child support obligations
and/or are you in arrears on such obligations for a period of six months or more? Yes _____ No _____
MAKING A FALSE STATEMENT MAY SUBJECT YOU TO CONTEMPT OF COURT.
For “No” response to either question contained in Question 12, refer to the website for an explanation of
supporting documentation requirements.
For “Yes” responses to Questions 13 thru 20, refer to the website for an explanation of supporting
documentation requirements.
Failure to provide the specific information requested will cause the application to be returned to you.
NOTE
: Disclosure of Social Security Numbers is mandatory for child support enforcement purposes. The
authority to compel disclosure of Social Security Numbers is established at P.L. 1996, c.7 and N.J.A.C. 3:1-20.
3
CERTIFICATION
I, the applicant, being duly sworn according to law depose and say that the answers set forth are true to
the best of my knowledge and belief. This application is made for the purpose of inducing the issuance of
a Banking License and I understand that any information withheld or which represents a material
misstatement will constitute grounds for rejection of this application by the Commissioner of Banking
and Insurance.
Signed, sealed and delivered in _______________________________________________
the presence (Print Name of Applicant)
_______________________________________________
(CORPORATE SEAL) (Signature of Corporate President, Member, Partner or Sole
(if applicable) Proprietor)
Attest: ____________________________________________
(Corporate Secretary or Witness)
Subscribed and sworn to before me at
__________________________________________________
this ______________day of_____________________20_____
__________________________________________________
__________________________________________________
(Official Title)
GENAPP212NJ
4
PERSONAL CERTIFICATION
(This blank form may be reproduced)
1. Name _____________________________________________________________________________________________
2. Residence Address ____________________________________________________
_______________________________
3. Business Address __________________________________________________________
__________________________
4. Date of Birth _________________________Place of Birth __________________________
_________________________
5. Telephone No. (_____)_______________
_______________________Social Security Number______________________
NOTE: Disclosure of Social Security Numbers is mandatory for child support enforcement purpose. The
authority to compel disclosure of Social Security Numbers is established by P.L. 1996, c.7 and N.J.A.C. 3:1-20.
6. Employment History for Five Year Period Preceding the Date of This Application
Date (Include present employment as well as preceding five years)
From To Name, Location & Type of Business Position & Nature of Duties
Attach additional sheet if more space is needed to complete employment history
7. Are you over 18 years of age? Yes _____ No _____. Are you a citizen of the United States? Yes_______ No_______. If no,
in what country do you hold citizenship? ____________________________.
8. Have you ever been arrested, indicted, convicted or pleaded “nolo contendere” to any offense, crime, or misdemeanor (other than
a motor vehicle violation) in this state, any other state, or any federal jurisdiction? Yes_______ No_______
If “yes”, complete
ARREST FORM
found on www.dobi.nj.gov.
9. Have any fines or penalties been levied against you by any state, municipality or federal agency? Yes_______ No_______
10. Have you been involved in any material litigation during the five-year period prior to application? Yes_______ No______
11. Are you now under investigation in this state, any other state, or federal jurisdiction? Yes _____ No _____
12. Have you ever held any license issued by the Department of Banking and Insurance? Yes _____ No _____
13. Have you ever had a license or right to engage in any business which is the subject of this application or any other business or
profession denied, revoked, suspended, otherwise restrained by any agency of this state, any other state, or by the federal
government? Yes_______ No_______
14. Have you ever filed a petition in bankruptcy or reorganization or been affiliated with any entity that has filed a petition in
bankruptcy or reorganization? Yes_______ No_______.
15. Are you the subject of an arrest warrant for failing to comply with court ordered child support obligations? Yes_____ No____
Are you in arrears on such obligations for a period of six months or more? Yes_____ No_____.
For “No” response to either question contained in Question 7, refer to the website for an explanation of supporting documentation
requirements.
For “Yes” responses to Questions 8 thru 15, refer to the website for an explanation of supporting documentation requirements
. Failure
to provide the specific information requested will cause the application to be returned to you.
Individual completing form check below:
Officer/Partner/Member/Owner______
Director ________
Stockholder ________
Employee ______
Page 1 of 2
CERTIFICATION
I, the applicant, being duly sworn according to law depose and say that the answers set forth are true to the best of
my knowledge and belief. This application is made for the purpose of inducing the issuance of a Banking
License or an approval under an existing license, and I understand that any information withheld or which
represents a material misstatement will constitute grounds for rejection of this application by the Commissioner
of Banking and Insurance. This authorizes release to the New Jersey Department of Banking and Insurance any
and all information pertaining to me, documentary otherwise, from all governmental agencies, federal, state and
local, without exception, both foreign and domestic. A photostatic copy of this authorization will be considered
as effective and valid as the original.
__________________________________________
Print Name
__________________________________________
Signature
__________________________________________
Title
__________________________________________
Date
Subscribed and sworn to before me
On this________________________ day of
__________________________, 20______
____________________________________
Title
PERSCERT811
Page 2 of 2
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NJ DEPARTMENT OF BANKING AND INSURANCE LICENSING SERVICES (State of New Jersey)

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Completed 9 March 2022

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