Fillable Photos #2 and #3 Photo #1 Application for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Photos #2 and #3 Photo #1 Application for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Photos #2 and #3 Photo #1 Application for (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 9 pages long and contains:

  • 8 signatures
  • 54 check-boxes
  • 114 other fields

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

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Application for Training Permit
Date:_______________________________
Pleaseencloseanonrefundableapplicationlingfeeof$50.00,alongwitha$50.00feeforatrainingpermit,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alsowillberequiredtopayacerticationfeeatalaterdate.
TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants, without their
consent. However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponseto
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
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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
Photo #1
Attachthreeclear,full-facepass-
port-stylephotographs(2˝x2˝)of
your head and shoulders, taken
withinthepastsixmonths.
Three photographs are required
witheachapplication.
Donotusestaplestoattachthe
photographs.
Photos #2
and #3
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)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeis
requiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovide
yourSocialSecuritynumberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. ChildSupport
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changedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
8. 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
9. 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.)
10. Do you currently hold, or have you ever held, a professional license, certicate or permit 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, certicate or permit 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,certicateorpermit Number Stateorjurisdictionthatissuedthelicense,certicateorpermit Dateissued/expired
_____________________ _______________________ ________________________________ __________________
Typeoflicense,certicateorpermit Number Stateorjurisdictionthatissuedthelicense,certicateorpermit Dateissued/expired
_____________________ _______________________ ________________________________ __________________
Typeoflicense,certicateorpermit Number Stateorjurisdictionthatissuedthelicense,certicateorpermit Dateissued/expired
_____________________ _______________________ ________________________________ __________________
Typeoflicense,certicateorpermit Number Stateorjurisdictionthatissuedthelicense,certicateorpermit Dateissued/expired
_____________________ _______________________ ________________________________ __________________
Typeoflicense,certicateorpermit Number Stateorjurisdictionthatissuedthelicense,certicateorpermit Dateissued/expired
11. Haveyoueverbeendisciplinedordeniedaprofessionallicense,certicateorpermitofanykindinNewJersey,anyotherstate,the
DistrictofColumbiaorinanyotherjurisdiction?   Yes No
12. Haveyoueverhadaprofessionallicense,certicateorpermitofanytypesuspended,revokedorsurrenderedinNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
13. 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
14. Have you ever been named as a defendant in any litigation related to any prior practice as a hearing aid dispenser, or other
professionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
15. Areyouawareofanyinvestigationpendingagainstaprofessionallicense,certicateorpermitissuedtoyoubyaprofessionalboardin
NewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
16. Arethere any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction?  Yes No
17. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgrouprelated
toanypriorpracticeasahearingaiddispenser,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11through17,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
AffidAvit of Good MorAl ChArACter
This afdavit is to be executed before a notary public:
Stateof:__________________________________________________
Countyof:________________________________________________
I, _________________________________________ ,ampersonallyacquaintedwith _____________________________________
andnotrelatedbybloodormarriagetotheapplicant.Ihaveknowntheapplicant_____________ .Iherebyattestthattheapplicantis
ofgoodmoralcharacterandrepute.
Name:________________________________________________________________________
Address: ______________________________________________________________________
Signature: _____________________________________________________________________
Swornandsubscribedtobeforemethis__________________
dayof ____________________________ ,______________
MonthYear
__________________________________________________
NameofNotaryPublic(pleaseprint)
__________________________________________________
SignatureofNotaryPublic
Afx Seal Here
} ss.
Nameofapplicant
Years/Months
click to sign
signature
click to edit
click to sign
signature
click to edit
WAiver
Iherebyauthorizeallinstitutions,myreferences,employerspastandpresent,businessandprofessionalassociations,andallprivate,
personneland government agencies orinstrumentalities (local, state, federal and foreign) to release tothe HearingAid Dispensers
ExaminingCommittee,anyinformationwhichismaterialtomyapplication.
Ihavecarefullyreadthequestionsinthisapplicationandhaveansweredthemcompletely,withoutreservationsofanykind,anddeclare
underpenaltyofperjurythatmyanswersandallstatementsmadebymehereinaretrueandcorrectandthatIamthepersonreferredto
inthisapplication.
ShouldIintentionallyfurnishanyfalseinformationinthisapplication,Iherebyagreethatsuchactsshallconstitutecausefordenial,
suspensionorrevocationofmylicensetopracticeasanHearingAidDispenserintheStateofNewJersey.
Ihavereadtheaboveandunderstandthesame.
__________________________________________________
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
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
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Hearing Aid Dispensers Examining Committee
Sponsor’s Afdavit
Please complete and return this afdavit with the completed application.
 I hereby afrm that I am currently licensed and registered to practice hearing aid dispensing in New Jersey. I have been
activelypracticinginNewJerseycontinuouslysince_____________.PursuanttoN.J.S.A.45:9A-16b,N.J.A.C.13:35-8.3andN.J.A.C.
13:35-8.6,Iherebyagree to assume full responsibility for the supervision and trainingof_____________________________
uponreceiptofaTrainingPermit,intherequisiteskills,methodsandtechniquessoastoensurecompetencyinthettingand
dispensingofhearingaids.Theapplicantwilltrain FULLTIME PARTTIMEatmybusinesslocation.Iwillassumefull
responsibilityforandguaranteethetrainee’sactivitiesintheselling,testing,ttinganddispensingofthehearingaids.
 PursuanttoN.J.S.A.45:9A-16aandN.J.A.C.13:35-8.5and8.6,Iwillassumefullresponsibilityforandguaranteethetemporary
licenseof_____________________________andhis/hersupervision,trainingandactivitiesintheselling,ttinganddispensing
ofhearingaids.
_______________________________________________________ ___________________________________
BusinessName  Telephonenumber(includeareacode)
________________________________________________________________________________________________________________________________________________________________________________________________________________
StreetAddress  City  State ZIPCode
Therm’sSupervisingLicensee’sname(N.J.A.C.13:35-8.8):
_______________________________________________________  ____________________________________
Name Licensenumber
Thesponsormust enclose copiesofhis/heroriginalN.I.H.I.S.certicatesindicatingthecompletionofaminimumof20continuing
educationcoursehoursduringthePREVIOUS BIENNIALREGISTRATION PERIOD.
____________________________________________________ ______________________________________________
Sponsor’sSignature   Date LicenseNumber
Swornandsubscribedtobeforemethis
dayof__________________________,_____________
Month Year
____________________________________________________________________________________
NameofNotaryPublic(pleaseprint)
____________________________________________________________________________________
SignatureofNotaryPublic
Afx Seal Here
click to sign
signature
click to edit
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
CertifiCation and authorization form
f
or a Criminal history BaCkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
LastFirstMiddle MaidenName
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
MonthDayYear 
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check
conducted for the Department of Education, another state agency or another state does not apply) you will not be required to
be ngerprinted a second time. However, the Division must perform a criminal history background check each time you apply
for licensure or certication. The fee for this service is $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
________________________
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
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Photos 2 and 3 Photo 1 Application for (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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