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

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

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New Jersey Ofce of Attorney General
Division of Consumer Affairs
Elevator, Escalator, and Moving Walkway
Mechanics Licensing Board
124 Halsey Street, 6th Floor, P.O. Box 45054
Newark, New Jersey 07101
(973) 504-6260
Application for an Elevator Mechanic’s License
Instruction Sheet
(Pursuant to N.J.A.C. 13:44M-2.1)
General Information
An individual who applies for the Elevator Mechanics license shall submit the following application. The application fee for the Elevator
Mechanics license application is $100.00 and is nonrefundable. The fee must be paid in the form of a check or money order made payable
to the State of New Jersey. The application must be neatly printed or typewritten. All sections of the application must be fully completed
before the application can be processed. If the application is not of sufcient size to furnish the required information, a supplemental
sheet of the same size may be enclosed with the application (please refer to the section for which you have used the supplemental sheet).
Applicants seeking licensure to engage in the Elevator Mechanics business must be 21 years of age or older.
The Afdavit section of the application must be executed and signed in the presence of a notary public. All applicants seeking licensure
to engage in the Elevator Mechanics business shall:
1. Have proof of successfully passing either the NAEC CET certication examination or the NEIEP examination;
2. An applicant for licensure shall have been employed for at least three years in the elevator, escalator, or moving walkway trade in
either;
1. New Jersey; or
2. Another state, if the applicant can show the years of employment completed in the other state would satisfy the experience and
training required to take the NAEC CET certication examination or the NEIEP examination.
Your application will be reviewed by the Elevator, Escalator, and Moving Walkways Mechanics Licensing Board once you have satised
these preliminary requirements.
Please be advised that if you have served in the Armed Forces of the United States and you do not meet all of the training, education,
and experience requirements for licensure under N.J.A.C. 13:44M-2.1, you may submit a request to the Board to consider your training,
education or experience while serving as a member of the Armed Forces towards the requirements for licensure.
New Jersey Ofce of Attorney General
Division of Consumer Affairs
Elevator, Escalator, and Moving Walkway
Mechanics Licensing Board
124 Halsey Street, 6th Floor, P.O. Box 45054
Newark, New Jersey 07101
(973) 504-6260
Applicant for an Elevator Mechanic’s License
Submissions Checklist
Applicant:
Please review this checklist before sending in your application. Any materials not included may cause a delay in the processing of your
application.
The application (Please note that every section must be completed.)
The nonrefundable application fee is $100.00
The application must be properly executed and notarized.
The applicant must:
Submit proof of completion of the NAEC CET certication examination or the NEIEP examination;
Submit proof of having been employed for at least three years in the elevators, escalators, or moving walkway trade in either
New Jersey; or
Another state, if you can show that the years of employment in the other state would satisfy the experience and training required
to take the NAEC CET certication examination or the NEIEP examination;
Submit a copy of birth certicate or other government document as proof of age.
New Jersey Ofce of Attorney General
Division of Consumer Affairs
Elevator, Escalator, and Moving Walkway
Mechanics Licensing Board
124 Halsey Street, 6th Floor, P.O. Box 45054
Newark, New Jersey 07101
(973) 504-6260
Application for an Elevator Mechanic’s License
Application date:_____________________ Certication number: _____________________________
Month Day Year
A nonrefundable application ling fee of $100, 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 examination 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
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
a. 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.
b. Are you over 21 years of age? Yes No
If “Yes,” please submit with this application a copy of your birth certicate or other government document as proof of your age.
If “No,” do not complete or submit this application. You do not meet the age requirement.
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photograph is required with
each application.
Do not use staples to attach the
photograph.
For Ofce Use Only
Approved
By ____________________
Date ___________________
Rejected
By ____________________
Date ___________________
Reason: __________________
_______________________
_______________________
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; and
b. the Probation Division or any other agency responsible for child support enforcement, upon request.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Child Support (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 or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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6. 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
If “Yes,” provide 10 year abstract.
Yes Nonon vult, nolo contendere, no contest, or a nding of guilt by a judge or jury.
7. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
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.)
8. 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 or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
First name Last name Middle initial
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicateType of license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicateType of license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicateType of license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicateType of license or certicate Date issued/expired
9. Have you ever been disciplined 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
10. 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
11. 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
12. Have you ever been named as a defendant in any litigation related to the practice of elevators, escalators, and moving walkway
mechanics installing, constructing, altering, serving, repairing, testing or maintaining elevators, and moving walkway or other
professional or occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
13. 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
14. 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
15. 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 elevators, escalators, and moving walkway mechanics installing, constructing, altering,
serving, repairing, testing or maintaining elevators, and moving walkway 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 9 through 15, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Experience
1. Detailed Statement of Experience
An applicant must provide proof of the following:
At least three years of completed work experience in the elevator, escalator, and moving walkway trade in either:
a) New Jersey; or
b) Another state, if the applicant can show the years of employment completed in the other state would satisfy the experience in
training required to take the NAEC CET certication examination or the NEIEP examination.
Dates
Month/Year
to
Month/Year
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
From __________
To _____________
Give a detailed account of experience, required by a) or b) above. Attach notarized afdavits from all employers
to verify your experience. Use additional sheets of paper if necessary.
Company’s name and address Duties
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the Elevator, Escalator, and Moving
Walkways Mechanic’s License Board for licensure or certication under the provisions of Title 45 of the General Statutes of
New Jersey and the Rules of the Elevator, Escalator, and Moving Walkways Mechanic’s License Board, 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 Board.
I further swear (or afrm) that I have read N.J.S.A. 45:14H-1 et seq., together with the Rules and Regulations of the Elevator,
Escalator, and Moving Walkways Mechanic’s License Board, N.J.A.C. 13:44M, and fully understand that in receiving
licensure from the Board, 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 Board.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
Afx Seal Here
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Elevator, Escalator, and Moving Walkway
Mechanics Licensing Board
124 Halsey Street, 6th Floor, P.O. Box 45054
Newark, New Jersey 07101
(973) 504-6260
Afx seal here
Elevator Mechanic’s License
Certication of Practical Experience
An applicant who is an employee of an Elevator Mechanic’s business must submit one (1) form for each employer who can certify
the applicant’s practical experience. An applicant who is an owner of an Elevator Mechanic’s business must submit two (2) forms from
other business owners engaged in the Elevator industry who can certify the applicant’s practical experience. You may make copies of
the form as needed.
A separate form must be completed for each reference you are submitting with your application for a license.
If performed outside of New Jersey, please explain the detailed work according to N.J.A.C. 13:44M-2.1
Please print clearly.
Applicant
Name _______________________________________________________________________________________________________
______________________________________________________________________________________________________
Street address City State ZIP code
Telephone number (include area code) ______________________________________________
Reference
Name _______________________________________________________________________________________________________
Company name ______________________________________________________________________________________________
_____________________________________________________________________________________________
Street address City State ZIP code
Telephone number (include area code) ______________________________________________
The applicant noted above has made application for a license issued by the Elevator, and Escalator, and Moving Walkway Mechanic’s
Licensing Board and has asked you to certify his/her practical experience.
1. How long have you known the applicant? ____________ years
2. The applicant has been employed in the Elevator Mechanic’s business for ____________ years.
This Afdavit must be executed before a Notary Public.
I, _______________________________________________, swear or afrm that all of the information I have provided herein with
regard to the applicant is true to the best of my knowledge and belief.
______________________________________________
Signature of reference
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
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New Jersey Ofce of Attorney General Application for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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