Fillable New Jersey Ofce of the Attorney General Checklist (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 Checklist (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 Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.NJConsumerAffairs.gov/nursing
Checklist for Temporary Courtesy License
Licensed Practical Nurse/ Registered Professional Nurse
NameofApplicant____________________________________________
SocialSecurityNumber______-_____-______
_______ Ihavereadtheapplicationinstructions.
_______ OfcialApplicationforaTemporaryCourtesyLicense(PleasemakesureALL
ofthequestionsareanswered.)
_______ Original2”x2”colorpassportphoto.(Photocopiesarenotacceptable.)
_______ Copyofapplicant’smilitaryID(orcopyofactivemilitaryspouse’sID)
_______ CopyofmilitaryordersassigningthemilitaryindividualtoNewJersey
_______ NotarizedAfdavit
_______ Supportingcourtdocuments(ifapplicable,refertoquestions10-18onthe
application,andquestion6ontheCerticationandAuthorizationform.)
_______ Birthcerticate(certiedEnglishtranslation,ifapplicable.)
_______ Immigrationdocumentation(ifapplicable,seequestion4,page2fordetails.)
_______ Proofoflegalnamechange(marriagecerticates,divorcedecrees,etc.,ifapplicable)
_______ CerticationandAuthorizationFormforaCriminalHistoryBackgroundCheck
(Makesureyousignanddatepage2.)
_______ Listofnursingemployers(seeapplication,page6)
_______ NewJerseyngerprintcard(black,ifapplicable)
_______ F.B.I.ngerprintcard(blue,ifapplicable)
_______ MorphoTrustuniversalform(boxes1-18havebeencompleted,ifapplicable)
_______ Ihavearrangedforlicensevericationstobesentforallotherstatesoflicensure.
(IftheyarenotavailableonNursys.)
_______ All required fees are included (application ($75.00), initial license ($60.00) and
surchargefee($5.00)foratotalof$140.00,madepayabletotheNewJerseyBoard
ofNursing;ngerprintingfeemadepayabletoMorphoTrust,ifapplicable).
I have completed all of the checklist items above.
____________________________________________

(SignatureofApplicant)
click to sign
signature
click to edit
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
www.NJConsumerAffairs.gov/nursing
INFORMATION REGARDING HOW TO APPLY FOR A
TEMPORARY COURTESY LICENSE
Enclosed is an application packet for a temporary courtesy license. Read the following information
carefully before completing this application.
If you previously held a license in New Jersey, DO NOT complete this application. You must
contact the Renewal Department in order to complete the Application for Reinstatement.
APPLICATION INSTRUCTIONS
1. Check the type of license for which you are applying.
2. Attach a clear, full-face original color passport photograph (2” x 2”) taken within the past
six months. Sign your name on the back of the picture.
3. Sign the application where indicated.
4. Complete the entire application and have it notarized.
5. Complete the Certication and Authorization form.
6. Complete the Morpho Trust universal form.
7. Complete two (2) ngerprint cards (one black (New Jersey), one blue (F.B.I.), if applicable).
8. Provide written verication of licensure in good standing from the state in which you were
originally licensed, or are currently licensed, and from every state in which you have ever
been licensed. The verication must be forwarded directly to the New Jersey Board of
Nursing from the applicable state board(s), if those state(s) are not listed on the NURSYS
License Verication Form.
9. Submit a personal check or money order in the amount of $140.00 made payable to the
New Jersey Board of Nursing.
10. Submit a personal check or money order in the amount of $58.65 for out-of-state applicants,
made payable to Morpho Trust.
11. Submit the signed and completed “Checklist for a Temporary Courtesy License.”
12. Submit all of the documents requested on the temporary courtesy license checklist.
GENERAL INFORMATION
We will make every effort to process your application in a timely manner. The process, however,
will be delayed if the application is incomplete or if any of the required documents have not been
submitted.
If you change your name and/or address after submitting an application for licensure, you must
notify the Board in writing immediately in order to receive important information.
It is the responsibility of the applicant to ensure that all of the required documentation has been
received by the Board in a timely fashion (including information from another state). Information
on the status of an application will be given to the applicant ONLY
.
Any incomplete application which has remained inactive for six months, will be destroyed in
accordance with the Division of Consumer Affairs’ record retention plan. To reactivate the
application process, a new application and fee are required.
Pursuant to N.J.S.A. 45:11-24.12a and N.J.A.C. 13:37-5.5(a)12, a $5.00 surcharge fee for the
alternative-to-discipline program is required.
NURSING PRACTICE ACT
It is the applicant’s responsibility to keep current on the laws pertaining to his or her practice,
the algorithm for determining the scope of nursing practice and the delegation of treatment
responsibilities, as these laws are subject to change. Please review the statutes and regulations on
the Board’s website at: http://www.njconsumeraffairs.gov/nur/Pages/regulations.aspx.
Revised 4/2015
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
www.NJConsumerAffairs.gov/nursing
Dear Applicant:
In November 2003, legislation was passed that requires the Division of Consumer Affairs to conduct
criminal history record background checks on all health care professionals prior to the issuance of an initial
license or other authorization to practice a health care profession (N.J.S.A. 45: 1-28 et seq.). The records of
the Division show that you are a current applicant for licensure or certication as a health care professional,
and as such, the Division must arrange to conduct a criminal history check of your background.
In order for the Division to conduct a criminal history record background check, you must complete the
enclosed Certication and Authorization form and return it to the mailing address above.
(In-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward your information
about how to schedule an appointment with MorphoTrust, Inc., to have your ngerprints electronically
recorded. A $62.70 ngerprinting fee must be paid to MorphoTrust, at the time of ngerprinting. The
$62.70 payment should be in the form of a check or money order made payable to MorphoTrust.
(Out-of-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward to you one
state and one federal ngerprint card. Out-of-state applicants must have their ngerprints recorded, on
the cards provided, by their local police department, by their state police department or by their local law
enforcement agency. You must return the ngerprint cards to the Board or Committee with the required
fee. Applicants submitting ngerprint cards will be required to pay a $58.69 fee to have their ngerprints
scanned into the electronic system by MorphoTrust. The $58.69 should be in the form of a check or money
order made payable to MorphoTrust.
If you fail to complete and return the Certication and Authorization form, your application for licensure or
certication will not be processed and your application will be considered abandoned.
The New Jersey Board of Nursing
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 a Temporary Courtesy License
for Military Personnel or Spouses of Military Personnel
Date:_______________________________
Pleaseencloseanendorsementapplicationlingfeeof$75.00,alicensecerticatefeeof$60.00anda$5.00surchargefee(foratotalof
$140.00)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$75.00feecoverstheapplicationonlyandthe$5.00surchargefeewillnotberefunded
orheldover.Onlythelicensecerticatefeeof$60.00isrefundableifyouaredeterminedtobeineligibleforlicensureorcertication.)
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
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
Applicant:
Checklicensetypefor
whichyouareapplying:
RegisteredProfessionalNurse
 LicensedPracticalNurse
Board Staff:
DatereceivedbytheBoard:
_________________________
LicenseorCerticatenumber:
_________________________
Attachaclear,full-facepassport
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.
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.
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).
5. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certicate unless you provide the
required documents concerning the plan for repayment of your student loan.
6. 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 -
Full name: ___________________________________________________________________________________________________
click to sign
signature
click to edit
7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical 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 those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity 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 applica
tion.
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 of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory
law. (N.J.S.A. 45:1-20.)
For the purposes of these questions, the following phrases or words have the following meanings:
“Ability to practice as a registered professional nurse or a licensed practical nurse” is to be construed to include all of the
following:
a. The cognitive capacity to exercise the reasonable judgments of a registered professional nurse or a licensed
practical nurse, and to learn and keep abreast of professional developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without the
use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of a registered professional nurse or a licensed practical nurse,
with or without the use of aids or devices, such as corrective lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
dia
betes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“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
two years.
“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.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you are not
eligible for licensure or certication.
____________________________________________________ ___________________________________
Applicant’s signature Date
- 3 -
Full name: ___________________________________________________________________________________________________
click to sign
signature
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8. 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.
9. Other Licenses:
a. Do you currently hold, or have you ever held, a professional license or certicate of any kind in New Jersey? Yes No
b. Do you currently hold, or have you ever held, a professional license or certificate of any kind in any other state, the
District of Columbia or in any other jurisdiction? Yes No
If you answered “Yes” to question 9a or 9b, for each license or certicate held, provide the date(s) held and the license number(s). If the license
or certicate was issued under a different name, please provide that name. ______________________________________________
Last name First name Middle initial
______________________ _______________________ ____________________________ ____________________
Type of license or certicate by State Board Exam
Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate by Endorsement
Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate by Endorsement
Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate by Endorsement
Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate by Endorsement
Number State or jurisdiction that issued the license or certicate Date issued/expired
10. 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
11. 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
12. 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
13. 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
14. 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
15. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. 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.)
16. 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
17. 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
18. 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 10 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
- 4 -
Full name: ___________________________________________________________________________________________________
Education
In the spaces below, give an accurate record of your educational preparation. Be sure to complete items A-D for each school. Use
additional sheets of paper if necessary.
A
B
C
D
A
B
C
D
A. Name of schools attended and locations
B. Number
of Years
Attended
C. Attendance
Entrance date
Leaving date
D. Title of diploma or degree
obtained*
Postsecondary School(s) including basic nursing
education 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
High School or Primary School
________________________________________________
Name of school
_____________________________ ________________
City State/Country
________________________________________________
Name of school
_____________________________ ________________
City State/Country
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
_____ / ____
Month Year
Check appropriate type:
Graduate diploma
Graduate equivalency
diploma
_____ / ____
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/diploma in the original language, attach a copy to this form.
- 5 -
Full name: ___________________________________________________________________________________________________
A. Name of schools attended and locations
B. Number
of Years
Attended
C. Attendance
Entrance date
Leaving date
D. Title of diploma or degree
obtained*
Check appropriate type:
L.P.N.
Certicate
Diploma
R.N.
Diploma
Associate’s Degree
Bachelor’s Degree
Nursing Work Experience
Do not include a curriculum vitae or a resume. Neither will meet the regulatory requirements for completing this application.
1. List the nursing experience you have acquired during the last ve years. Provide the information about your current employment
rst. Use additional sheets of paper if necessary.
(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: ____________________________________________________________________
Important Information
1. You must be at least 18 years old to apply for a temporary courtesy license.
2. Verication forms from every state or jurisdiction in which you have been licensed or certied must be sent directly to the New
Jersey Board of Nursing by the board of nursing in each state or jurisdiction.
- 6 -
Full name: ___________________________________________________________________________________________________
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 through 13:37-16.16
, 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.
__________________________________________________
Applicant’s signature
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 -
Full name: ___________________________________________________________________________________________________
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
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 $17.50. 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. 10/1/16
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
License Verication Request
Directions to applicant: Complete only the top portion of this license verication form and forward it to the Board of Nursing in the state(s)
in which you are or have been licensed. The board(s) should complete the form and return it to the New Jersey Board of Nursing. Note: Be
advised that the board(s) completing the form may charge a fee for license verication. Please call the board(s) to check on fees for license
verication prior to submitting this form. If any state in which you are licensed is a member of Nursys
®
, please use the NCSBN Nursys
®
form in order for us to receive your verifications faster. (Please see the complete instructions on the NCSBN Nursys
®
form.)
Registered Nurse Licensed Practical Nurse
Name: ___________________________________________________________________________________
First name Middle name Last name Maiden name, if applicable
Name on original license: _________________________________ Telephone number: __________________
(include area code)
Current address: ____________________________________________________________________________
Street City State ZIP
School of nursing: _________________________________ Location: ________________________________
Year of graduation: ________________ License number: _____________________ Year issued: ____________
Directions to State Board of Nursing:
This section is to be completed by the State Board of Nursing.
* Please include this form with any verication or correspondence sent to the New Jersey Board of Nursing at the address above.
1. License registration number: __________________________________ Date: ____________________________
2. Did the applicant graduate from a board accredited or approved school of nursing? Yes No
3. State Board examination scores: (If the exams were taken prior to 1949, please list the subjects and scores.)
Score Series Score Series
Medical nursing Surgical nursing
Nursing of children Obstetric nursing
Psychiatric nursing N.C.L.E.X.
4. Was license issued by:
State Board test pool exams?
Yes No Score _____________ Series ______________
N.C.L.E.X.? Yes No Score _____________ Series ______________
Waiver? Yes No Date
Endorsement? Yes No Date ______________________________
5. Has this license ever been revoked, suspended or voluntarily surrendered? Yes No
I
f “Yes,” please provide a description of the charge(s) and any action(s) taken and provide a copy of any
complaint, order and voluntary surrender document.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I certify that the statements contained herein are true to the best of my belief,
and I recommend this nurse for licensure in the State of New Jersey.
Secretary ______________________________________________________
State __________________________________________________________
Date __________________________________________________________
Ofcial
Seal
Alabama (334) 242-4060
Alaska (907) 269-8161
Arizona (602) 331-8111
Arkansas (501) 686-2700
California RN (916) 322-3350
California PN (916) 263-7800
Colorado (303) 894-2430
Connecticut (860) 509-7624
Delaware (302) 739-4522
Washington DC (202) 442-4380
Florida (904) 858-6940
Georgia RN (912) 207-1640
Georgia PN (912) 207-1640
Hawaii (808) 586-3000
Idaho (208) 334-3110
Illinois (312) 814-2715
Indiana (317) 232-2960
Iowa (515) 281-3255
Kansas (785) 296-4929
Kentucky (502) 329-7000
Louisiana RN (504) 838-5332
Louisiana PN (504) 838-5791
Maine (207) 287-1133
Maryland (410) 585-1900
Massachusetts (617) 727-9961
Michigan (517) 373-9102
Minnesota (612) 617-2270
Mississippi (480) 987-4188
Missouri (573) 751-0681
Montana (406) 444-2071
Nebraska (402) 471-4376
Nevada (775) 688-2620
New Hampshire (603) 271-2323
New Jersey (973) 504-6430
New Mexico (505) 841-8340
New York (518) 474-3843
North Carolina (919) 782-3211
North Dakota (701) 328-9777
Ohio (614) 466-3947
Oklahoma (405) 962-1800
Oregon (503) 731-4745
Pennsylvania (717) 783-7142
Rhode Island (401) 222-2827
South Carolina (803) 896-4550
South Dakota (605) 362-2760
Tennessee (615) 532-5166
Texas RN (512) 305-7400
Texas PN (512) 305-8100
Utah (801) 530-6628
Vermont (802) 828-2396
Virginia (804) 662-9909
Washington RN (360) 236-4713
Washington PN (360) 236-4713
West Virginia RN (304) 558-3596
West Virginia PN (360) 558-3572
Wyoming (307) 777-7601
Outside Continental USA
American Samoa (684) 633-1222-206
In the United States
Guam 011(671) 475-0251
N. Mariana Island 01-670-234-8950
through 8954
Puerto Rico (787) 725-8161
(Only if NCLEX Exam was taken.)
Virgin Island (340) 776-7397
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New Jersey Ofce of the Attorney General Checklist (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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