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

Fill Online, Printable, Fillable, Blank New Jersey Ofce of the Attorney General INSTRUCTIONS (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 76 minutes to complete

The New Jersey Ofce of the Attorney General INSTRUCTIONS (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 19 pages long and contains:

  • 7 signatures
  • 15 check-boxes
  • 270 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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/nur/Pages/default.aspx
INSTRUCTIONS FOR ADVANCED PRACTICE NURSE CERTIFICATION IN N.J.
Please note that, pursuant to N.J.A.C. 13:37-7.2 an applicant must have completed his or her
education no more than two years prior to submitting an application for certication. An education
program completed more than two years prior to submission shall not qualify an applicant for
certication.
Please read the following information carefully before completing an application for APN
Certication.
If you previously held APN Certication in New Jersey, DO NOT complete this application. Please
contact Rosann Lyons at (973) 273-8040 from the Board of Nursing.
1. Hold a current, active, and valid New Jersey license as a Registered Professional Nurse.
2. Request an application for APN Certification by submitting a request to:
apn@dca.lps.state.nj.us.
3. Complete the application. Answer ALL of the questions.
4. Sign the application in the presence of a notary public.
5. Attach a clear, full-face original passport photograph (2” x 2”) of your head and shoulders
taken within the past six months. Sign your name on the back of the picture. (Photocopies
and selfies are not acceptable.)
6. If you are a U.S.-born citizen, please submit a copy of your birth certificate or U.S. passport.
7. If you are a naturalized U.S. citizen, please submit a copy of your U.S. passport or certificate
of naturalization.
8. If you are a legal alien or other immigration status, please submit your USCIS immigration
documents. (Submit a copy of both the front and the back of your card.)
9. Submit proof of a legal name change (i.e., marriage license, divorce decree, court order) if
your name differs from that on your birth certificate.
10. Complete the Certification and Authorization form for a criminal history background
check and submit a check in the amount of $18.75 made payable to the State of New Jersey
for a fingerprint archive request.
11. Submit criminal history documents (if applicable).
12. Arrange to have a transcript from your master’s or doctoral program submitted directly to
the Board.
13. Arrange to have proof of valid APN Certication within your specialty from your national
credentialing agency submitted directly to the Board.
14. 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.
15. Submit proof of completion of six (6) contact hours of a pharmacology course related to
C.D.S.
16. Submit Certicates of Completion of 30 continuing education credits in pharmacology,
if you graduated from your master’s/doctoral program more than ve (5) years ago.
17. Submit the nonrefundable application fee in the amount of $100.00, made payable to the
New Jersey Board of Nursing, in the form of a check or money order.
18. You will receive a letter from the Board advising you of the initial certication fee due,
either $80.00 or $160.00, based on the expiration date of your RN license.
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
Application for Advanced Practice Nurse Certication
(Do not submit this application unless and until you hold an active, valid New Jersey R.N. License.)
Date:_______________________________
Pleaseencloseanonrefundableapplicationlingfeeof$100.00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.)Youwillalsoberequired
topayacerticationfeeatalaterdate.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. 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(includingyouraddressofrecord)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name 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
Attachaclear,full-facepassport-
stylephotograph(2˝x2˝)ofyour
headandshoulders,takenwithin
thepastsixmonths.
A photo is required with each
application.
Donotuse staplesto attach the
photo.
3. SocialSecurityNumber
Youmustprovide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)Aof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. 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
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
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applicationforlicensureorcerticationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainst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 nurse”istobeconstruedtoincludeallofthefollowing:
a. The cognitive capacity to exercise the reasonable judgments of a 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 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.
____________________________________________________ ___________________________________
Signatureofapplicant Date
click to sign
signature
click to edit
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. 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. ____________________________________________________________________
 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
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.
19.AreaofClinicalSpecialty:______________________________
The New Jersey Board of Nursing only recognizes certain categories of Advanced Practice Nurses.
20.NewJerseyRegisteredNurselicensenumber:_______________________________
21.Areyoucertiedorlicensedforadvancednursingpracticeinanotherstate(s)?  Yes No
If“Yes,”specifystate(s)ofcerticationorlicensure._________________________
You will need to obtain verication from these states. Refer to the enclosed Verication Request Form.
22.Entry-LevelNursingEducationCompleted: Diploma  AssociateDegree BaccalaureateDegree
________________________________________________________________________________________________

Nameofnursingschool Dategraduated Credential

Entry-LevelC.R.N.A.EducationifnotMaster’sDegree,asappropriate
________________________________________________________________________________________________

Nameofprogram Dategraduated Credential
23.GraduateNursingEducationCompleted:
(Please have the ofcial transcript(s) sent directly to the New Jersey Board of Nursing from the graduate nursing program(s).)
 Master’sDegreeinNursing: ______________________________________ __________________________________
  
Areaofspecialty Dategraduated

NameofMaster’sinNursingProgram:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Streetaddress City State ZIPcode
 Post-Master’sNursingCerticateProgram:__________________________ __________________________________

AreaofspecialtyDategraduated
NameofPost-Master’sCerticateProgram:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Streetaddress City State ZIPcode
24.PharmacologyEducationCompleted:
GraduateLevelThree-CreditCourse _______________________________

Datecompleted
30HoursofPharmacology*_____________________________________ __________________________________

DatecompletedNo.ofintegratedpharmacyhours

(*If pharmacology was integrated into various courses (rather than a separate pharmacology course), please complete the enclosed
Completion of Integrated Pharmacology Form.)
Six(6)ContactHoursinpharmacologyrelatedtocontrolleddangeroussubstances,includingpharmacologictherapy,andaddiction
 preventionandmanagement.
(Please complete the enclosed form.)

25.NationalClinicalSpecialtyCertication:  Yes NoCite7.1(b)
(Please have the Certifying Agency submit verication of your certication directly to the Board.)
NameofCertifyingAgency:_______________________________________________________________________________
Name(s)ofcertifyingexamination(s)thatyoupassed/specialty: __________________________________________________
_______________________________________________________________________________________________________
Certicationdate:From ___________________to __________________________
If you are not certied, please complete the following:
NameofCertifyingExamination_____________________________
NameofCertifyingAgency_________________________________
Scheduledtestdate:_______________________________________

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,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.
click to sign
signature
click to edit
click to sign
signature
click to edit
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evidenceofrehabilitationmust 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
________________________
APN
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
Advanced Practice Nurse Certication:
Completion of Integrated Pharmacology
Thiswillcertifythat___________________________________________________________,completedatleast______ hours of

Nameofgraduate
pharmacologyintegratedintotheadvancednursingpracticeprogramcompletedat_________________________________________
Nameofnursingprogram
on________________________________ .
Date
Iherebycertifythattheabovestatementistrueandcorrectand
afxmyhandandschoolsealthis ______________________
dayof ____________________________ ,______________
MonthYear
__________________________________________________
NameofDean/Director(pleaseprint)
__________________________________________________
SignatureofDean/Director
______________________________________________________________________________________

NameofControllingInstitute
______________________________________________________________________________________
CityStateZIPcode
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
School
Seal
Here
Pharmacology Continuing Education Compliance Report Form
Name:_________________________________________________________R.N.LicenseNumber:_______________________

A.P.N.Specialty/Category:______________________________________________


I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if
any of the foregoing statements made by me are willfully false, I am subject to punishment, including but not
limited to suspension or revocation of a license and/or certication under N.J.S.A. 45:1-21.
Signature: ___________________________________________________________
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
Title of Program
Attach copies of the certicates*
Date
Program Provider
Contact
Hours
1 contact hour = 50 minutes
1 C.M.E./1 A.M.A. = 60 minutes = 1.2 contact hours
A total of 30 contact hours is required.
Total
_______
*Attach a copy of the program certicate of completion/attendance (usually one page) for each listing noted
above to add up to 30 contact hours.
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
Advanced Practice Nurse Certication Verication Request:
Certication of Advanced Nursing Practice
Directions: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.
Applicantname:___________________________________________________________________________
Firstname MiddlenameLastname  Maidenname,ifapplicable
Currentaddress:____________________________________________________________________________
Street City State ZIPcode
This section is to be completed by the State Board of Nursing.
Iherebycertifythat_______________________________________________ wasissuedcertication/licensure
Name
asa________________________________________________________________________________________
ClinicalSpecialty
(Checkone): NursePractitioner ClinicalNurseSpecialist
intheStateof__________________________________________________ on___________________________ .

Date
Thiscertication/licensureexpireson_______________________________ .

Date
Hasanydisciplinaryactionbeentakenagainstanylicenseorcerticationissuedtothisnursetopracticenursing?
(Checkone): Yes No
I
f“Yes,”pleaseexplain:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Icertifythatthestatementscontainedhereinaretruetothebestofmybelief,
andIrecommendthisnursefor
advancednursingpracticecerticationintheStateofNewJersey.
__________________________________________

ExecutiveOfcer
__________________________________________

NewJerseyBoardofNursing
__________________________________________

Date
Return to: New Jersey Board of Nursing, P.O. Box 45010, Newark, N.J. 07101
Ofcial
Seal
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document