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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Forensic Nurse - Certied Sexual Assault
Application Instruction Sheet
Enclosed is an application packet for the New Jersey Board of Nursing’s Forensic Nurse - Certied Sexual
Assault Certication. Please read all of the directions carefully and return to the Board the completed
Ofcial Application for Forensic Nurse - Certied Sexual Assault.
Return completed materials to:
New Jersey Board of Nursing
P.O. Box 45010
Newark, NJ 07101
Initial Application
For the initial applicant, the following requirements must be fullled. Send directly to the Board:
• The $100.00 nonrefundable application fee and the $100.00 certication fee. (See fees.)
• The New Jersey Board of Nursing’s Ofcial Application for Forensic Nurse - Certied Sexual
Assault.
• The Certication and Authorization form for the criminal history background check.
• A letter or certicate of completion of a FN program in the U.S., or a transcript which must include
the ofcial school seal.
• Proof of successfully completing the clinical requirements (N.J.A.C. 13:37-9.6).
Endorsement Application
For the endorsement applicant, the following requirements must be fullled. Send directly to the Board:
• The $100.00 nonrefundable application fee and the $100.00 certication fee.
• The New Jersey Board of Nursing’s Ofcial Application for Forensic Nurse - Certied Sexual
Assault.
• The Certication and Authorization form for the criminal history background check.
• A letter or certicate of completion of a FN program in the U.S., or a transcript which must include
the ofcial school seal.
• Verication of certication as a FN in another state.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
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).
Fees
Initial Application and Endorsement Application
Please enclose a nonrefundable application ling fee of $100.00 and a license certicate fee of $100.00
(Note: The certicate fee is $100.00 if paid during the rst year of the biennial renewal period for your R.N.
license, or $50.00 if paid during the second year of the biennial renewal period for your R.N. license.) in the
form of a check or money order made out to the State of New Jersey. (Applicants should understand that if
the fees are 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 fees are paid.)
Questions
Address questions to Ms. Leslie Burgos at (973) 504-6457.
F.N. - C.S.A. Certication Application Information
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Ofcial Application for Forensic Nurse Examiner - Certied Sexual Assault
Please put a check in the box next to the category of certication you are seeking:
Initial Endorsement
Date: _______________________________
Please enclose a nonrefundable application ling fee of $100.00 and a license certicate fee of $100.00 (Note: The certicate fee is
$100.00 if paid during the rst year of the biennial renewal period for your R.N. license, or $50.00 if paid during the second year of the
biennial renewal period for your R.N. license.) in the form of a check or money order made out to the State of New Jersey. (Applicants
should understand that if the fees are 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 fees are 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
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
Date received:
_________________________
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months, with your
name printed on the back of the
photo.
A photo is required with each
application.
Do not use staples to attach the
photo.
- 1 -
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 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
- 2 -
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6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous 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 this question 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 application. 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 on the Fifth Amendment, provided that the Attorney General rst grants you immunity
afforded by statutory law, (N.J.S.A. 45:1-20).
“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
365 days, whichever is longer.
“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.
a. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
- 3 -
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7. 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.
8. 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 provide that name. ____________________________________________________________________
First name Middle initial Last name
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
_____________________ _______________________ ____________________________ ____________________
Number State or jurisdiction that issued the license or certicate Date issued/expiredType of license or certicate
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
9. 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
10. 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
11. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice
by any agency or certication 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 nursing or other professional practice in New
Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
13. 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
Yes Nonon vult, nolo contendere, no contest, or a nding of guilt by a judge or jury.
14. 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.)
15. 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
16. 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
17. 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 nursing 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 9 through 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 4 -
Education
In the spaces below, give an accurate record of your educational preparation. Be sure to complete items A through D for each school.
Use additional sheets of paper if necessary.
A
B
C
D
Postsecondary school(s) including basic nursing education
and forensic nurse (FN) programs
________________________________________________
Name of school Program major
_____________________________ ________________
City State/Country
________________________________________________
Name of school Program major
_____________________________ ________________
City State/Country
________________________________________________
Name of school Program major
_____________________________ ________________
City State/Country
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
* Note: If your professional school was located outside the U.S., and you have a copy
of your degree or diploma in the original language, attach a copy to this form.
- 5 -
Forensic Nurse
Forensic Nurse
Nursing Work Experience
List the nursing experience you have acquired as a registered professional nurse. Provide the information about your current
employment rst. Use additional paper if necessary.
If you are applying for certication as a forensic nurse examiner - certied sexual assault by endorsement, indicate the places
you have worked as a forensic nurse examiner.
Do not include a curriculum vitae or resume. Neither will meet the regulatory requirements for completing this application.
(a) Employer: __________________________________________________________________________________
Address: ___________________________________________________________________________________
Street address City State ZIP code
Telephone number:_____________________________
(include area code)
Title of your position: ___________________________________________ Hours per week: _______________
From ________________________________________ to ___________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ___________________________________________________________
(b) Employer: __________________________________________________________________________________
Address: ___________________________________________________________________________________
Street address City State ZIP code
Telephone number:_____________________________
(include area code)
Title of your position: ___________________________________________ Hours per week: _______________
From ________________________________________ to ___________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ___________________________________________________________
(c) Employer: __________________________________________________________________________________
Address: ___________________________________________________________________________________
Street address City State ZIP code
Telephone number:_____________________________
(include area code)
Title of your position: ___________________________________________ Hours per week: _______________
From ________________________________________ to ___________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ___________________________________________________________
- 6 -
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 New Jersey Board of Nursing for
licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the New Jersey Board of
Nursing, 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. 45:11-23 et seq., together with the Rules and Regulations of the New Jersey Board
of Nursing, N.J.A.C. 13:37-1.1 et seq., and fully understand that in receiving licensure or certication 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
__________________________________________________
Name of Notary Public (please print)
Afx Seal Here
__________________________________________________
Signature of Notary Public
} ss.
- 7 -
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Ofcial Use Only
Dual License
Forensic Nurse
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CertifiCAtion And AuthorizAtion form
for 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
certification 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.
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
Forensic Nurse
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
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Forensic Nurse - Certied Sexual Assault
License/Certication
Verication Request
Direction: Complete only the top portion of this license/certication form and forward it to the license/certication
agency in the state in which you are licensed/certied. The agency should complete the form and return it to the New
Jersey Board of Nursing, Forensic Nurse - Certied Sexual Assault. Note: Be advised that the agency completing
the form may charge a fee for license/certication verication. Please call the agency to check on fees for license/
certication verication prior to submitting this form.
Name: _______________________________________________________________________________________
First Name Middle Name Last Name Maiden Name, if applicable
Name on original license/certication: __________________________ Telephone number: ___________________
(include area code)
Current address: _______________________________________________________________________________
Street City State ZIP code
License/Certication number: _______________________________ Year issued: _______________
This section is to be completed by the state licensing/certication agency.
1. License/Certication number: __________________________Date issued: ____________________________
2. When was the license/certicate last renewed? _____________
3. Is the license/certicate in good standing? Yes No
4. Has this license/certication ever been revoked, suspended or voluntarily surrendered or has any action been
taken by your agency against this licensee? Yes No
If “Yes,” please provide a description of the reason and/or charge(s) and any action(s) taken and provide a copy
of any complaint, order or relevant document.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I certify that the statements contained herein are true based upon ofcial records
that I reviewed.
Print Name _____________________________________________________________________
Signature _______________________________________________________________________
Title ___________________________________________________________________________
State ________________________________Date _______________________________________
Ofcial
Seal
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Completed 15 August 2020

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