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

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

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Architects
124 Halsey Street, 3rd Floor, P.O. Box 45001
Newark, New Jersey 07101
(973) 504-6385
Attention: New Jersey Licensed Architect:
Attached is an application for licensure pursuant to N.J.A.C. 13:27-4.12 et seq. Scope of practice; Home Inspections.
This law provides that a Board-licensed architect may apply to the Board for certication of eligibility for licensure
as a home inspector.
For your guidance you will nd a copy of the regulation governing the licensure of home inspectors and an application
listing all the required information for submission. If you meet the Boards education, training and experience require-
ments, please complete the application and return it accompanied with a check or money order in the amount of
$125.00 (an application fee) made payable to the New Jersey State Board of Architects.
Also, please be advised that N.J.S.A. 45:8-76 and N.J.S.C. 13:40-15.8, require that every licensed home inspector and
associate home inspector engaged in the profession of home inspection shall secure, maintain and le with the Home
Inspection Advisory Committee, proof of a certicate of an errors and omissions insurance policy in the minimum amount
of $500,000.00 per occurrence. Therefore, please instruct your insurance carrier to submit proof of this coverage
by providing an original certicate of insurance, stating all individuals covered under the policy, directly to the
Board of Architects. Copies or Facsimiles will not be accepted. If the certicate of insurance is in the name of the
company, the insurance carrier must inform the Committee ofce of the individual(s) who are covered by the listing
their name(s). Finally, the Home Inspection Advisory Committee must be referenced as a certicate holder in the
event that the policy is renewed, altered or canceled.
Should you have any questions feel free to contact the ofce at (973) 504-6385.
Very truly yours,
New Jersey State Board of Architects
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Architects
124 Halsey Street, 3rd Floor, P.O. Box 45001
Newark, New Jersey 07101
(973) 504-6385
Home Inspector Licensure Application for Architects
Date: ____________________________
N.J. architect’s license number: _____________________________________
A nonrefundable application ling fee of $125 in the form of a check or money order made out to the New Jersey State Board of Architects,
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
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.
For Ofce Use Only
Application number:
_________________________
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
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
6. Have you ever been convicted of a criminal offense? (Minor trafc offenses such as parking or speeding violations need not be
listed; however, motor vehicle offenses such as driving while impaired or intoxicated must be disclosed.) 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.)
7. Other than your license as an architect in New Jersey, do you currently hold, or have you ever held, a professional 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 proivde that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
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
_____________________ _______________________ ____________________________ ____________________
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
8. Have you ever been disciplined or denied a professional license or certicate of any kind in New Jersey, any other state, the District
of Columbia or in any other jurisdiction? Yes No
9. Have you ever had a professional 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
10. 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
11. Have you ever been named as a defendant in any litigation related to the practice of architecture, home inspection or other
professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
12. Are you aware of any investigation pending against a professional license or certicate issued to you by a professional board in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. 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
14. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of architecture, home inspection 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 8 through 14, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Proof of Insurance
N.J.S.A 45:8-76 requires that every “licensed home inspector and associate home inspector who is engaged in home inspection shall
secure, maintain and le with the board proof of a certicate of an error and omissions policy, which shall be in a minimum amount of
$500,000 per occurrence. Every proof of an error and omissions policy required to be led with the board shall provide that cancellation
or nonrenewal of the policy shall not be effective unless and until at least 10 days’ notice of intention to cancel or nonrenew has been
received in writing by the board.”
____________________________________________________________________________________________ _______________________________________________________________________________
Name of agent Name of insurance company
__________________________________________________________________________________________________________________________________________________________________________________________
Street City State ZIP code County
_______________________________________________________ ___________________________________________________________________ __________________________________________________
Telephone number (include area code) Policy number Expiration date
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Employment Record
Current Employment Employee Owner Shareholder
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Previous Employment Employee Owner Shareholder
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Employee Owner Shareholder
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Training
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Experience
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
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
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             

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New Jersey Ofce of the Attorney General (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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