Fillable Photo #2 Photo #1 New Jersey Ofce of (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Photo #2 Photo #1 New Jersey Ofce of (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
State Board of Professional Engineers and Land Surveyors
Home Inspection Advisory Committee
124 Halsey Street, 3rd Floor, P.O. Box 45043
Newark, New Jersey 07101
(973) 504-6233
Application for Licensure as a Home Inspector
Date:
A nonrefundable application ling fee of $125, in the form of a check or money order made payable 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 (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: ________________________
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
For Ofce Use Only
Application number:
_________________________
Photo #1
Photo #2
Attach two clear, full-face pass-
port-style photographs (2˝x 2˝)
of your head and shoulders, taken
within the past six months.
Two photographs are required
with each application.
Do not use staples to attach the
photographs.
- 1 -
Rev. 6/28/16
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;and
b. theProbationDivisionoranyotheragencyresponsibleforchild-supportenforcement,uponrequest.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresultinadenialof
licensureorcertication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimited
to,immediaterevocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
-2-
click to sign
signature
click to edit
6. 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
7. 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provideacompleteexplanation.
(Attachadditionalsheetsofpapertothisapplication.)
8. Do you currently hold, or have you ever held, a professional or occupational license or certificate (i.e. radon
measurement technician or specialist, radon mitigation technician or specialist, etc.) 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).Ifthe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
9. HaveyoueverbeendisciplinedordeniedaprofessionaloroccupationallicenseorcerticateofanykindinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
10. Haveyoueverhadaprofessionaloroccupationallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,
anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
11. Hasanyaction(includingtheassessmentofnesorotherpenalties)everbeentakenagainstyourprofessionaloroccupational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
12. Haveyoueverbeen named asa defendant in anylitigation related to thepractice of home inspectionor other professional or
occupationalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
13. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a
professionalorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?
Yes No
14. 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
15. Haveyoueverbeensanctionedbyorisanyactionpending before any employer,association, society,or other professional or
occupationalgrouprelatedtothepracticeofhomeinspectionorotherprofessionaloroccupationalpracticeinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
Iftheanswertoanyoftheabovequestions,numbers9through15,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
-3-
Proof of Insurance
N.J.S.A. 45:8-76 requires that every “licensed home inspector who is engaged in home inspection shall secure, maintain and le with
the board proof of a certicate of an error and omissions policy, which shall be in a minimum amount of $500,000 per occurrence. Every
proof of an error and omissions policy required to be led with the board shall provide that cancellation or nonrenewal of the policy shall
not be effective unless and until at least 10 days’ notice of intention to cancel or nonrenew has been received in writing by the board.”
____________________________________________________________________________________________ _______________________________________________________________________________
Name of agent Name of insurance company
_______________________________________________________________
___________________________________________________________________________________________________________________________
Street City State ZIP code County
_______________________________________________________
___________________________________________________________________ __________________________________________________
Telephone number (include area code) Policy number Expiration date
Education
1. What is the name and address of the high school you attended? _____________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. What years did you attend high school? _____________________
3. Did you graduate from high school? Yes No
If “Yes,” what was the date of your graduation? ______________________________
Month Year
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date certicate was issued
4. (Complete this section if you are applying for licensure pursuant to N.J.S.A. 45:8-68c(1)).
N.J.S.A. 45:8-68c(1) requires that “a home inspector has successfully completed an approved course of study of 180
hours which shall include not less than 40 hours of unpaid field-based inspections in the presence of and under the direct
supervision of a licensed home inspector, which inspections shall be provided by the school providing the approved course of study.”
Please indicate the name and address of the educational institution that offered the approved course of study you completed.
Attach a copy of the certicate of completion furnished by the school.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date completed
- 4 -
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date completed
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date completed
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date completed
5. Have you taken the National Home Inspector examination administered by the Examination Board of Professional Home Inspectors
(EBPHI)? Yes No
If “Yes,” please indicate the date you passed the examination. __________________________________________
Date
- 5 -
Home Inspection Experience (Complete this section if you are applying for licensure pursuant to N.J.S.A. 45:8-68c(2).)
As per N.J.S.A. 45:8-68c(2), an applicant must “Have performed not less than 250 fee-paid home inspections in the presence of
and under the direct supervision of a licensed home inspector who oversees and takes full responsibility for the inspection and any
report produced....” Please have the licensed home inspector complete the Certication of Providing Direct On-Site Supervision
for a Home Inspector Applicant.
Date of inspection
Name of client
Address of inspection
Name and license number of
supervising home inspector
- 6 -
Employment Record
(Please list any and all previous employment history even if not related to home inspection.)
Current Employment Employee Owner Shareholder
a.
Name of company or private practice Street address
City State ZIP code Telephone number (include area code)
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from to
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities:
Previous Employment Employee Owner Shareholder
b.
Name of company or private practice Street address
City State ZIP code Telephone number (include area code)
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from to
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities:
Employee Owner Shareholder
c.
Name of company or private practice Street address
City State ZIP code Telephone number (include area code)
Name of supervisor
Supervisor’
s title
Applicant’s title
Dates of employment: from to
Month/Year Month/Year Total hours worked per week
Description of job functions and responsibilities:
- 7 -
Afx Seal Here
- 8 -
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 Home Inspection 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 Home Inspection 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. 45:8-61 et seq., together with the Rules and Regulations of the Home
Inspection Advisory Committee, N.J.A.C. 13:40-15.1 through 13:40-15.23, 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, agen-
cies 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
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
Home Inspection Advisory Committee
124 Halsey Street, 3rd Floor, P.O. Box 45043
Newark, New Jersey 07101
(973) 504-6233
Certication of Providing Direct On-Site Supervision
For a Home Inspector Applicant
The purpose of this form is as follows: A New Jersey licensed Home Inspector must attest to the fact that he or she
has been present for and provided direct supervision to the applicant for licensure as a Home Inspector during the
applicant’s performance of the 250 required inspections and/or 40 hours of eld inspections provided by an approved
school. Additionally, the New Jersey licensed Home Inspector must take full responsibility for the inspections and any
report produced from said inspections. [See N.J.S.A. 45:8-68 et seq. and N.J.A.C. 13:40-15.6a]
Certication of Direct On-Site Supervision
I,_______________________________________________________,incompletingthiscerticationfor theHome
InspectionAdvisoryCommittee,havebeenpresentforandprovideddirectsupervisionover_________(#)traininginspectionsto
__________________________________________(name of applicant)inhisorherquesttoqualifyasaHomeInspector.
Theseinspectionswereperformedduringtheperiodof___/___through___/___.Eachinspectionhasbeenidentied
below. 
Mo.Yr.

Mo.Yr.
I(theapplicant)furtherswear(orafrm)thatIhavereadN.J.S.A.45:8-61etseq.,togetherwiththeRulesandRegulations
oftheHomeInspectionAdvisoryCommittee,N.J.A.C.13:40-15.1through15.23,andfullyunderstandthatinreceiving
licensurefromtheCommittee,IhaveboundmyselftobegovernedbyN.J.S.A.45:8-61etseq.andN.J.A.C.13:40-15.1
through15.23.
Signatureoflicensee NewJerseyHomeInspectionLicenseNumber
Signatureofapplicant NewJerseyApplicationNumber
Client’s
Telephone
Number
Date of
Inspection
****Attachadditionalsheetsofpaperifneeded.
Client’s Name
Client’s Address
-9-
Representative’s
Name and
Telephone Number
(If applicable)
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Photo 2 Photo 1 New Jersey Ofce of (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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