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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PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
BMEPA@dca.lps.state.nj.us
Physician Assistant Application for Licensure Checklist
Use this checklist as a guide to assure your application is complete.
Applicant’s name:______________________________________________________________
I. Application
A. Answer each question completely.
B. Be sure to have the application notarized.
C. Attach one (1) passport photograph (2” x 2”) to the application.
D. Provide a valid daytime telephone number (include area code).
E. Attach additional documents (if applicable). (For example, to explain gaps in curriculum vitae history, a
statement of medical activity, or other.)
List here:
_______________________________________________________________________________________
_______________________________________________________________________________________
F. Provide the original or a notarized copy of your birth certicate, a notarized copy of your passport or
citizenship documents.
G. Provide name-change documentation (a notarized copy of the marriage license/court orders (if applicable)).
II.
Verication forms
a. Military Service Prole (PA-94-ll-A) Yes N/A
b. P.A. License(s)/Registration (PA-94-ll-B) Yes N/A
c. N.C.C.P.A. Vercation (PA-94-ll-C) Yes
d. Certication of Good Standing (PA-94-ll-D) Yes N/A
e. Verication of Graduation from a Physician Assistant Program
(with one (1) passport photograph (2” x 2”) (PA-94-ll-F) attached).
f. Employer(s) Verication of Hospital/Medical Employment, Privileges or Appointment (PA-94-ll-H)
PROOF
Checklist
III. Transcripts: Verication of Education
A. Physician Assistant Program
IV. Curriculum Vitae
V. Application Fee
Personal check or money order payable to the Physician Assistant Advisory Committee, in the amount of
$125.00. (This fee is not refundable.)
VI. Certication and Authorization Form for a Criminal History Background Check.
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
BMEPA@dca.lps.state.nj.us
Dear Applicant:
Enclosed please nd a New Jersey application for licensure. Please be advised that pursuant to N.J.S.A. 45:9-27.13
“The Physician Assistant Licensing Act” provides for licensure of applicants who have met the following criteria.
1. The applicant is at least 18 years of age.
2. The applicant is of good moral character.
3. The applicant has successfully completed an approved program, meaning the applicant is a graduate of a
Physician Assistant Program that has been approved by the Committee on Allied Health Education and
Accreditation, or its successor, and
4. The applicant has passed the national certifying examination administered by the National Commission on
Certication of Physician Assistants, (the “N.C.C.P.A.”) or its successor.
Currently, there are no provisions for the licensure of non-United States accredited medical graduates as Physician
Assistants who have not met the requirements outlined above.
In order for your application to be processed, you must adhere to the following guidelines in conjunction with the
checklist provided. Failure to answer each question completely will result in your application being returned to you for a
response.
Very Important
Please read the application form in its entirety before completing. Note: Under the Medical Conditions section of the
application, there are instances when “not applicable” may apply.
It will be your responsibility to contact the N.C.C.P.A. and have them send us your verication or certication.
I. Verication Forms A-H (These forms may be duplicated if necessary.)
The issuing authority, state or employer must return the applicable form directly to the Physician Assistant
Advisory Committee at the address listed on the form. Forms submitted to the Physician Assistant Advisory
Committee by an applicant will not be accepted.
A. Military Service Prole (PA-94-II-A)
Forward a copy of this form to every branch of the U.S. military service in which you have served. The
military branch(es) should be advised that proles that are incomplete will not be accepted.
B. Certication of Physician Assistant License/Registration/Permit Issued (PA-94-II-B)
Forward a copy of this form to each state where you were licensed or are currently licensed as a
physician assistant.
PROOF
C. Certication of Good Standing (PA-94-II-D)
Forward a copy of this form to each state/country where you are currently, or have been in the past,
licensed/certied as a health care professional other than a physician assistant. For example, as a physician,
nurse, paramedic, X-ray technician, respiratory therapist, E.M.T., etc.
D. Verication of Graduation from a Physician Assistant Program (PA-94-II-F)
Please attach a passport-size photograph (2” x 2”) taken within the past six (6) months. Please forward
this form to your Physician Assistant Program to verify your graduation. This form must be mailed
directly to the Physician Assistant Advisory Committee.
E. Verication of Medical Employment Form (PA-94-II-H)
Forward a copy of this form to every medical facility or hospital/medical employer for whom you
have worked in a medical capacity within the past ve (5) year period that immediately precedes the
submission of your application for licensure in New Jersey.
Please ensure that your employer understands that this form must be completed in its entirety, and
then sent to the Committee along with a letterhead and/or business card. Incomplete verication forms will
not be accepted. Please Note: This form must be mailed by the employer and must not be submitted by the
applicant.
II. Verication of Education
All applicants must request ofcial transcripts from the Physician Assistant Program attended to. The transcripts
must be mailed or emailed, directly from the schools. Transcripts submitted to the Physician Assistant
Advisory Committee by the applicant will not be accepted.
III. Curriculum Vitae/Resume
Note: List all activities chronologically, including formal education, professional experiences/employment
and activities. Also, include a rationale for any gaps in your employment or education. Be sure to provide
addresses and phone numbers for all employers.
IV. Fees
Please forward a check or money order in the amount of $125.00 with your application. If approved
for licensure, you will be notied to forward the licensure fee of $220.00 for a permanent license.
V.
Certication and Authorization Form for a Criminal History Background Check
Complete this form in its entirety and mail it to the address on top of page one of the checklist. Please do
not send any fees
when returning the Certication and Authorization Form. Upon receipt of the Certication and
Authorization Form, a Sagem Morpho letter will be sent to each applicant with instructions regarding how
to proceed to have the ngerprint process completed.
If you answered “Yes” to question six (6), please submit a written explanation to the Physician Assistant
Advisory Committee. Also, contact the court involved and have the court forward a copy of the Indictment,
the Judgment of Conviction and the Transcript of Sentencing to the address on top of page one of the checklist.
If you have any questions or need assistance, contact the Physician Assistant Advisory Committee at
(609) 826-7100
.
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Physician Assistant Application for Licensure
Date : ____________________________
A nonrefundable application ling fee of $125.00, in the form of a check or money order made out to the State of New Jersey,
must be submitted with this application. (Applicants should understand that if the application ling fee is paid with a personal
check, and the check is returned by the bank due to insufcient funds, the next step in the licensure or certication process will
be delayed until the fee is paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State Country
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
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.
PA-94-1
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. 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
click to sign
signature
click to edit
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
click to sign
signature
click to edit
7. 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
8. 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.)
9. HaveyoueverservedintheArmedForcesoftheUnitedStates? Yes No
If“Yes,”submitacopyofyourmilitarydischargedocumentsandseetheinstructionsontheCommittee’sMilitaryServiceProle
form(PA9411-A).
10. Have you previouslyapplied for a license or certicate asaphysician assistant in New Jersey, any other state, the District of
 Columbiaorinanyotherjurisdiction? Yes No
If“Yes,”whenandwhere?_________________________________________________
11. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykind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
(IfyouholdacerticateissuedbytheNationalCommissiononCerticationofPhysicianAssistants(N.C.C.P.A.),youmustcontactthe
CommissiontorequestthatdocumentationconrmingyouracquisitionofthecerticatebeforwardeddirectlytotheCommittee.)

12. HaveyoueverbeendisciplinedordeniedalicenseorcerticateasaphysicianassistantoranyotherprofessionallicenseinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
13. 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
14. 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
15. Haveyoueverbeennamedasadefendantinanylitigationrelatedtopracticeasaphysicianassistantoranyotherprofessional
practiceinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
16. Areyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyany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practiceasaphysicianassistantorany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12through18,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
PROOF
Education
1. What is the name and address of the Physician Assistant Program(s), that you attended?
Name of college or university Dates attended (from/to)
Street address City State ZIP code
Name of college or university Dates attended (from/to)
Street address City State ZIP code
Name of college or university Dates attended (from/to)
Street address City State ZIP code
A curriculum vitae is required. Label all gaps in chronological order and provide a rationale for each gap.
PROOF
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 Physician Assistant Advisory
Committee for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules
of the Physician Assistant Advisory Committee, 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 Committee.
I further swear (or afrm) that I have read N.J.S.A. 45:9-27.10 et seq., together with the Rules and Regulations of the Physician
Assistant Advisory Committee, N.J.A.C. 13:35-2B.1 et seq., and fully understand that in receiving licensure or certication
from the Committee, 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 Committee.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
Afx Seal Here
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
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 background process.
Please send no payment 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 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 re-
quired 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.
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
________________________
PROOF
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
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Military Service Prole
Applicant’s name:___________________________________________________________________________
Applicant’s rank :___________________________________________________________________________
Branch of service:___________________________________________________________________________
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 140 East Front Street, P.O. Box 183,
Trenton, New Jersey
08625. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
1. What position and rank does this individual hold or did he/she hold when discharged?
_____________________________________________________________________________________
_____________________________________________________________________________________
2. What were this individual’s dates of service?__________________________________________________
3. What type of discharge did this individual receive?____________________________________________
a. What was the date of discharge?________________________________________________________
4. Was the individual on probation, suspended or in any way sanctioned/disciplined while in the military?
Yes No
5. Was this individual granted a leave of absence while in the military? Yes No
6. Were any restrictions placed on this individual’s activities which were not placed on all other personnel
holding similar positions? Yes No
7. Would this individual be recommended for re-enlistment? Yes No
If “No,” please explain._________________________________________________________________
____________________________________________________________________________________
8. Would this individual be recommended for promotion? Yes No
If “No,” please explain._________________________________________________________________
____________________________________________________________________________________
PA-94-ll-A
PROOF
9. Did quality assessment review of this individual ever result in a negative nding? Yes No
If “Yes,” please explain._________________________________________________________________
_____________________________________________________________________________
10. Was this individual in the Medical Corps? Yes No
If “Yes,” please answer questions A-H:
A. Was this individual denied clinical privileges while in the military? Yes No
B. Were any restrictions placed on this individual’s clinical privileges? Yes No
C. Were any formal patient or staff complaints led against this individual? Yes No
D. Were any incident reports led involving the professional conduct or behavior
of this individual? Yes No
E. Was this individual ever subject to nonroutine monitoring while in the
military service? Yes No
F. Was this individual removed from a call schedule for cause? Yes No
G. Was this individual subject to nonroutine quality assessment review? Yes No
H. Would you recommend this individual for privileges at a hospital? Yes No
Please supply any additional comments or information that the Committee should consider prior to determining
this applicant’s eligibility for licensure.
_________________________________________________________________________________________
_________________________________________________________________________________________
Please print the name of the individual supplying the information: ____________________________________
Signature of the individual supplying the information: _____________________________________________
Address and full telephone number where the individual supplying the information may be contacted:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Date form was completed: ___________________________________________________
Please return directly to: State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street - 3rd oor
P. O. Box 183
Trenton, NJ 08625
Please
Afx
Ofcial
Seal
Here
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Certication of Physician Assistant License/Registration/Permit Issued
Please complete the top portion only and forward one form to each state where you hold or have held a license
to practice as a Physician Assistant. Extra copies may be photocopied if needed.
This section is to be completed by the applicant:
I,________________________________________, am applying for a New Jersey Physician Assistant License.
The New Jersey Physician Assistant Advisory Committee requests that I submit evidence that my License/Registration
in the State of _______________________________________________________________is in good standing.
I was granted License/Registration Number_____________________________on ______________________.
Date
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 140 East Front Street, P.O. Box 183,
Trenton, New Jersey
08625. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
This section is to be completed by an Ofcial of the Issuing Authority:
Please complete and return this form to: Dept. of Law & Public Safety, Division of Consumer Affairs, Physician
Assistant Advisory Committee, P.O. Box 183, Trenton, New Jersey 08625.
Name:____________________________________________________________________________________
License/registration number :__________________ Date issued: ____________ Expiration date: ___________
Is license/registration current? Yes No
If “No,” please explain: ______________________________________________________________________
__________________________________________________________________________________________
Is license/registration in good standing? Yes No
If “No,” please explain:_______________________________________________________________________
__________________________________________________________________________________________
Additional information or other remarks:________________________________________________________
_______________________ _________________________________ ____________________________
Date Print name Signature
_____________________________________ _______________________________________________
State Board Title
(Seal of attesting Issuing Authority must be impressed over signature.)
PA-94-ll-B
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Score Release Form
National Commission on Certication of Physician Assistants
Certication Verication Request
Section I Instructions to Applicant
For the Committee to obtain verication of your N.C.C.P.A.
credentials, complete the following information, sign, date and
send this form to the N.C.C.P.A., 12000 Findley Road, Suite #200
Duluth, GA. 30097.
Section II Personal Information and Signature
Print your name as it appears on your Certicate and your address.
_________________________________________________________________________________________
Last name First name Middle initial Former name
_________________________________________________________________________________________
Address Apt. number
_________________________________________________________________________________________
City State ZIP code
Registered to take exam on: Date: ______________________________
Completed exam on: Date: _____________________________________
Certicate number: __________________________ Expiration date:_______________________
I hereby give my permission to the N.C.C.P.A. to verify my credentials to the New Jersey Physician
Assistant Advisory Committee pursuant to N.J.S.A. 45:9-27.13 et seq.
_________________________________________ ___________________________
Signature Date
PA-94-ll-C
click to sign
signature
click to edit
click to sign
signature
click to edit
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Certication of Good Standing Non-Physician Assistant
License/Registration/Permit Issued/Certication
Please complete the top portion only and forward one form to each state where you hold or have held a state
issued license, permit or certicate as a health care provider other than a physician assistant. Extra c
opies may be
photocopied if needed.
This section is to be completed by the applicant:
I,_________________________________________ am applying for a New Jersey Physician Assistant License.
The New Jersey Physician Assistant Advisory Committee requests that I submit evidence that my License/Registration
in the State of _______________________________________________________________is in good standing.
I was granted License/Registration Number_____________________________on ______________________ .
Date
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 140 East Front Street, P.O. Box 183,
Trenton, New Jersey
08625. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
This section is to be completed by an Ofcial of the Issuing Authority:
Please complete and return this form to: Dept. of Law & Public Safety, Division of Consumer Affairs, Physician
Assistant Advisory Committee, P.O. Box 183, Trenton, New Jersey 08625.
Name:____________________________________________________________________________________
License/registration number :__________________ Date issued: ____________ Expiration date: ___________
Is license/registration current? Yes No
If “No,” please explain: ______________________________________________________________________
__________________________________________________________________________________________
Is license/registration in good standing? Yes No
If “No,” please explain:_______________________________________________________________________
__________________________________________________________________________________________
Additional information or other remarks:________________________________________________________
_______________________ _________________________________ ____________________________
Date Print name Signature
_____________________________________ _______________________________________________
State Board Title
(Seal of attesting Issuing Authority must be impressed over signature.)
PA-94-ll-D
PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Verication of Graduation from a Physician Assistant Program
Part 1 - Directions for applicant:
Complete the top of this page and send this form to the director of your Physician Assistant Program for completion
of Part 2.
Name:___________________________________________________________________
Last First
Address:_________________________________________________________________
Street City State ZIP code
_________________________________________________________________________________________
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 140 East Front Street, P.O. Box 183,
Trenton, New Jersey
08625. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
Part 2 - Directions for Program Director:
Complete the bottom portion of this page and return it directly to the Physician Assistant Advisory Committee.
1. (a) Did the individual noted above attend your program? Yes No
(b) Is the individual whose photograph is attached,
the individual who attended this Physician Assistant Program? Yes No
2. What were the applicant’s dates of enrollment in the program? From_____________ to _____________.
3.
Did this individual complete all of the requirements of the
Physician Assistant Program? Yes No
If “No,” please explain: _________________________________________________________________
4. What was the date of graduation? __________________________________________
5. Did this individual take a leave of absence during his/her attendance at this Physician Assistant Program?
Yes No
If “Yes,” please explain: _________________________________________________________________
6.
Was this individual on probation during his/her attendance at this Physician Assistant Program?
Yes No
If “Yes,” please explain: _________________________________________________________________
7.
Was this individual ever disciplined or under investigation during his/her attendance at this Physician
Assistant Program? Yes No
8. Were any negative reports led by instructors regarding this individual? Yes No
9.
Were any special requirements imposed on this individual that were not required of all other students at
his/her level of education? Yes No
10.
Please supply any additional comments or information that the Committee should consider prior to determining
this applicant’s eligibility for licensure.
_____________________________________________________________________________________
PA-94-ll-F
Attach
Photo
Here
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 124 Halsey Street, P.O. Box 45035, Newark, New Jersey
07101. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
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signature
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PROOF
I hereby certify that the person whose name is on this form successfully completed the Physician Assistant
Program and that his/her scholastic standing and practical performance were satisfactory during the course of
study
completed.
Name of institution:__________________________________________________________________________
Address of institution:________________________________________________________________________
__________________________________________________________________________________________
Name of the Director of the Program (please print): ________________________________________________
Signature of the Director of the Program: ____________________________________ Date: _______________
Please return directly to: State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor
P. O. Box 183
Trenton, NJ 08625
Afx
School
Seal
PA-94-ll-F
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signature
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PROOF
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Verication of Hospital/Medical Employment, Privileges or Appointment
Applicant’s name:___________________________________________________________________________
Name of Hospital/Facility:____________________________________________________________________
Hospital/Facility address:_____________________________________________________________________
Hospital/Facility’s telephone number (include area code): ___________________________
You are hereby authorized to release any information in your les, favorable or otherwise, directly to the New
Jersey Physician Assistant Advisory Committee, 140 East Front Street, P.O. Box 183,
Trenton, New Jersey
08625. Your early attention is appreciated.
__________________________________________ ______________________________
Applicant’s signature Date
1. What position did this health practitioner hold at your facility? __________________________________
2. What were this health practitioner’s dates of employment at your facility?
From: ____________________ to: _______________________.
3. Was this health practitioner placed on probation, suspended or in any way
sanctioned/disciplined while at your facility? Yes No
4. Was this health practitioner granted a leave of absence while employed at
your facility? Yes No
5. Were any restrictions placed on this health practitioner’s activities that were
not placed on all other employees holding similar positions? Yes No
6. Were any restrictions placed on this health practitioner’s privileges? Yes No
7. Were any formal patient or staff complaints led against this health practitioner? Yes No
8. Were any incident reports led involving the professional conduct or behavior of
this health practitioner? Yes No
9. Was this health practitioner ever subject to nonroutine monitoring while
at your facility? Yes No
10. Was this health practitioner involuntarily removed from a call schedule for cause? Yes No
11. Was this health practitioner subject to nonroutine quality assessment review? Yes No
12. Was this health practitioner the subject of a negative review by a quality assurance
or departmental committee? Yes No
13. Was this health practitioner the subject of an investigation by your facility or any
PA-94-ll-H
PROOF
committee or department of your facility? Yes No
14. Were any malpractice actions led naming this health practitioner as a defendant
that involved his/her period of employment at your facility? Yes No
If you answered “Yes” to any of the above questions 1-14, please explain: ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
15. Did this health practitioner leave your facility in good standing? Yes No
16. Would you consider rehiring this health practitioner for a position at your facility? Yes No
17. Would you recommend this health practitioner for privileges at your facility? Yes No
If you answered “No,” to questions 15, 16 or 17, please explain: ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
18.
Please supply any additional comments or information that the Committee should consider prior to determining
this
applicant’s eligibility for licensure.
_____________________________________________________________________________________
_____________________________________________________________________________________
Please print the name and title of the Certifying Ofcial:_______________________________________________
Signature of the Certifying Ofcial: _______________________________________________________________
Date the form was completed: _____________________
Please attach a letterhead or some form of identication such as a business card for the individual supplying this information.
Please return directly to: State Board of Medical Examiners
Physician Assistant Advisory Committee
140 East Front Street, 3rd Floor
P. O. Box 183
Trenton, NJ 08625
PA-94-ll-H
Seal of
Hospital
(If applicable)
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New Jersey Ofce of the Attorney General (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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