Fillable Polysomnography Trainee - Provisional License New Jersey Ofce (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Polysomnography Trainee - Provisional License New Jersey Ofce (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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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 Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Polysomnography Trainee - Provisional License
Date:________________________________
Anonrefundableapplicationlingfeeof$100.00 andalicensefeeof$50.00(foratotalof$150.00)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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.)
Iftheapplicationprocessisnotcompletedwithinoneyear,yourapplicationwillbediscardedandyouwillneedtore-applywith
fullpayment.
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
otherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddress
ofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureof
yourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleased
tothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.
InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Dateofbirth:_______________________
MonthDayYear
Placeofbirth: ______________________
 CityState
Mr.
1. Name Mrs. ____________________________________________________________ (______________________)
Ms.
Lastname Firstname Middleinitial Maidenname
2. Address
Home:_________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
____________________________________ _________________________________
Telephonenumber(includeareacode) E-mailaddress
 Business:_______________________________________________________________________________________
Nameofcompany Telephonenumber(includeareacode)
________________________________________________________________________________________
Street City State ZIPcode County
 Mailing:________________________________________________________________________________________
StreetorP.O.Box City State ZIPcode County
Datereceived:
_________________________
Dateofexamination:
_________________________
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.
Pleasesignandprintyourname
onthebackofthephoto
Page1of9
3. SocialSecurityNumber
YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/nonrenewalof
licensureorcertication.
*SocialSecurityNumber:  __________ -____________ -___________
*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupport
EnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeis
requiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovide
yourSocialSecuritynumberto:
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing
compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and
c. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship/ImmigrationStatus
FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcerticatestoU.S.citizensorqualiedaliens.
Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued
yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. ChildSupport(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
Page2of9
click to sign
signature
click to edit
7. MedicalConditionsQuestions
Questionsathroughfpertaintomedicalconditionsanduseofchemicalsubstances.Pleasereadthedenitionscarefully.Your
responseswillbetreatedcondentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthose
portionsofthefollowingquestionswhichinquireastotheillegaluseofcontrolleddangeroussubstancesoractivityifyouhave
reasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayassert
theFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.If
youchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplica
tion.
YourapplicationforlicensureorcerticationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.
Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefused
toansweronthebasisoftheFifthAmendment,providedthattheAttorneyGeneralrstgrantsyouimmunityaffordedbystatutory
law.(N.J.S.A.45:1-20.)
Forthepurposesofthesequestions,thefollowingphrasesorwordshavethefollowingmeanings:
“Ability to practice as a polysomnography trainee”istobeconstruedtoincludeallofthefollowing:
a. Thecognitivecapacitytoexercisethereasonablejudgmentsofapolysomnographytraineeandtolearnandkeepabreastof
professionaldevelopments;and
b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtoclientsandotherinterestedparties,withorwithoutthe
useofaidsordevices,suchasvoiceampliers;and
c. Thephysicalcapabilitytoperformthedutiesofapolysomnographytrainee,withorwithouttheuseofaidsordevices,suchas
correctivelensesorhearingaids.
“Medical Condition”includesphysiological,mentalorpsychologicalconditionsordisorders,suchas,butnotlimitedtoorthope
dic,
visual,speechandhearingimpairments,cerebralpalsy,epilepsy,musculardystrophy,multiplesclerosis,cancer,heartdisease,
dia
betes,mentalretardation,emotionalormentalillness,speciclearningdisabilities,H.I.V.disease,tuberculosis,drugaddiction
andalcoholism.
“Chemical substance”isto be construed to include alcohol, drugsormedications,includingthosetakenpursuanttoa valid
pre
scriptionforlegitimatemedicalpurposesandinaccordancewiththeprescriber’sdirection,aswellasthoseusedillegally.
“Currently”doesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,
itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactonone’sfunctioningasalicensee,orwithinthe
previoustwoyears.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionor
nottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.
a.
Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonable
skillandsafety? Yes  No
b. Arethelimitationsorimpairmentscausedbyyour medicalconditionreducedoramelioratedbecauseyoureceiveongoing
treatment(withorwithoutmedications)orparticipateinamonitoringprogram**?
Yes  No Notapplicable
c. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseoftheeldofpractice,
thesettingormannerinwhichyouhavechosentopractice? Yes  No Notapplicable
d. Doesyouruseofchemicalsubstance(s)inanywayimpairorlimityourabilitytopracticeyourprofessionwithreasonableskill
andsafety? Yes  No Notapplicable
e. Haveyoueverbeendiagnosedashavingorhaveyoueverbeentreatedforpedophilia,exhibitionismorvoyeurism?
Yes  No
f. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Recallthat“currently”isdenedas“within
thelasttwoyears.”) Yes  No
Ifyouanswered“Yes” to question f, areyoucurrentlyparticipatinginasupervised rehabilitation program or professional
assistanceprogramwhichmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangerous
substances? Yes  No
** Ifyoureceivesuchongoingtreatmentor participateinsuchamonitoringprogram,theBoardwill makeanindividualized
assessmentofthenature,theseverityandthedurationoftherisksassociatedwithanongoingmedicalconditionsoastodetermine
whetheranunrestrictedlicenseorcerticateshouldbeissued,whetherconditionsshouldbeimposedorwhetheryouarenot
eligibleforlicensureorcertication.
____________________________________________________ ___________________________________
Signatureofapplicant Date
Page3of9
click to sign
signature
click to edit
8. Haveyoueverchangedyourname? Yes No
If“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecerticate,divorcedecreeorcourtorder.
9. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcerticateofanykindinNewJersey,anyotherstate,the
DistrictofColumbiaorinanyotherjurisdiction Yes No
If“Yes,”foreachlicenseorcerticateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcerticatewasissuedunder
adifferentname,pleaseprovidethatname.____________________________________________________________________
LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________
Typeoflicenseorcerticate Number Stateorjurisdictionthatissuedthelicenseorcerticate Dateissued/expired
10. HaveyoueverbeendisciplinedordeniedaprofessionallicenseorcerticateofanykindinNewJersey,anyotherstate,theDistrictof
Columbiaorinanyotherjurisdiction?   Yes No
11. Haveyoueverhadaprofessionallicenseorcerticateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,
theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
12. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice
byanyagencyorcerticationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? 
  Yes No
13. Haveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofpolysomnographyorotherprofessionalpractice
inNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?   Yes No
14.Have youever been summoned; arrested; taken into custody;indicted; tried; chargedwith; admitted into pre-trial intervention
(P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother
state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle
violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No
15. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty,
nonvult,nolocontendere,nocontest,orandingofguiltbyajudgeorjury.  Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation.(Attachadditionalsheetsofpapertothisapplication.)
16. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcerticateissuedtoyoubyaprofessionalboardinNew
Jersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction?  Yes No
17. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyother
jurisdiction?  Yes No
18. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgroup
relatedtothepracticeofpolysomnographyorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaor
inanyotherjurisdiction?  Yes No
Iftheanswertoanyoftheabovequestions,numbers10through18,is“Yes,”provideacompleteexplanationofthecircumstances
leadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
Page4of9
Trainee Education
1. Whatisthenameofthehighschoolyouattended?Ifyoudidnotgraduatefromahighschool,donotlistanyschool.
______________________________________________________________

Nameofhighschool
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youhavegraduatedfromahighschool,arrangefortheschooltoforwardproofofgraduationdirectlytotheStateBoardof
Polysomnography.)
If“No,”didyoustudytoreceiveaG.E.D.certicate? Yes No
Ifyouhavenotgraduatedfromhighschool,submitproofthatyouholdaGeneralEducationalDevelopment(G.E.D.)certicate.
ProvidethenameoftheAccreditedSleepTechnologistEducationProgram(A-STEP)IntroductoryCoursethatyoucompletedas
wellasthenameandaddressoftheentitythatofferedthecourse.
_____________________________________________ _________________________________

NameofcourseDatesattended
________________________________________________________________________________________________________________________________________________________________________________
Name
andaddressofentityofferingA-STEPcourse
ArrangefortheentitythatofferedtheA-STEPIntroductoryCoursethatyoucompletedtoforwardproofofcompletiondirectlyto
theStateBoardofPolysomnography.
Proof of Completion of A-STEP Introductory Course Online Exam:
E-mail method (preferred)
Pleasee-mailastep@aasmnet.org withthefollowing:
Placeinthesubjectline: NJ A-STEP Verication
Inthebodyofthee-mailinclude:
Your full name
Cutandpastethefollowing:
I am requesting that the American Academy of Sleep Medicine forward proof of my successful completion of the A-STEP Introductory
Course Online Examination to the New Jersey State Board of Polysomnography at njpolysomnography@dca.lps.state.nj.us .
Basic Life Support
Youmustprovideproofthatyouholdacurrent(notexpired)certicationinBasicLifeSupportfortheHealthProviderfromtheAmerican
HeartAssociationorCardio-PulmonaryResuscitation/AutomatedExternalDebrillator(CPR/AED)fortheProfessionalRescuer
fromtheAmericanRedCross.
Pleaseprovideacopy(frontandback)ofyourcertication.

Page5of9
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 State Board of Polysomnography,
for licensure or certication under the provisions ofTitle 45 of the General Statutes of New Jersey and the Rules of the State
Board of Polysomnography, swear (or affirm) that I am the applicant and that all information provided in connection
withthisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomake
fulldisclosuresmaybedeemedsufcienttodenylicensureorcerticationortowithholdrenewaloforsuspendorrevokealicenseor
certicateissuedbytheBoard.
Ifurtherswear(orafrm)thatIhavereadN.J.S.A.45:14G-1etseq.,togetherwiththeRulesandRegulationsoftheStateBoardof
Polysomnography,N.J.A.C.13:44etseq.,andfullyunderstandthatinreceivinglicensureorcerticationfromtheBoard,Ibindmyself
tobegovernedbythem.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
thepurposeofverifyingmyqualicationsforlicensureorcertication.Ifurtherauthorizeallinstitutions,employers,agenciesandall
governmentalagenciesandinstrumentalities(local,state,federalorforeign)toreleaseanyinformation,lesorrecordsrequestedby
theBoard.
__________________________________________________
Signatureofapplicant
Swornandsubscribedtobeforemethis__________________
dayof ____________________________ ,______________
MonthYear
__________________________________________________
NameofNotaryPublic(pleaseprint)
__________________________________________________
SignatureofNotaryPublic
Afx Seal Here
} ss.
Page6of9
click to sign
signature
click to edit
click to sign
signature
click to edit
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
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
click to sign
signature
click to edit
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Polysomnography
124 Halsey Street, 7th Floor, P.O. Box 45051
Newark, New Jersey 07101
(973) 273-8093
Trainee Supervision Form
_____________________________________________, who is licensed as a physician or polysomnographic
(Nameofsupervisor)
technologistinNewJersey,willactasprimarysupervisorfor_______________________________________________
(Nameofapplicant)
and is aware that he or she, or another physician or polysomnographic technologist licensed in New Jersey,
shall be continuously on-site and available to render immediate physical assistance whenever
__________________________________________________________ is acting as a polysomnographic trainee.
(Nameofapplicant)
_________________________________________________willmaintainarecordofthenameandlicensenumberof
(Nameofsupervisor)
thelicensedphysicianorpolysomnographictechnologistwhoissupervising__________________________________
(Nameofapplicant)
whileheorsheisactingasapolysomnographictrainee.
______________________________________________________________________________________
Printnameofsupervisor Nameofapplicant
______________________________________________________________________________________
Signatureofsupervisor Signatureofapplicant
_____________________________________________________________________________________
Date Date
_______________________________________________
Licensenumberofsupervisor
Facility’sname:_____________________________________________________________________________
Facility’saddress:___________________________________________________________________________

Street CityStateZIPcode
Facility’stelephonenumber:____________________________
(includeareacode)
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Polysomnography Trainee - Provisional License New Jersey Ofce (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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