Fillable Proof 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 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 Professional Engineers and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Instructions for Completing the Application
for Reinstatement or Reactivation
Please be advised that under the New Jersey Uniform Enforcement Act (N.J.S.A. 45:1-7.1(b)), a license shall
be suspended 30 days following the expiration date. A license may be reinstated provided that the applicant
otherwise qualies for licensure, and complies with the provisions of N.J.S.A. 45:1-7.4.
1. Reinstatement:
a. Submit a completed reinstatement application.
b. Submit a signed and dated certication of employment listing each job held during the period of
suspended license, which includes the names, addresses, and telephone numbers of each
employer.
c. Submit payment of the renewal fee ($80.00) for the biennial renewal period for which
reinstatement is sought.
d. Submit payment of the unpaid renewal fee ($80.00) for the biennial period immediately preceding
the renewal period for which reinstatement is sought.
e. Submit payment of a reinstatement fee ($125.00).
f. Submit proof of having completed required continuing education credits.
2. Reactivation:
a. Submit a completed reinstatement application.
b. Submit a signed and dated certication of employment listing each job held during the period of
suspended license, which includes the names, addresses, and telephone numbers of each
employer.
c. Submit payment of the renewal fee ($80.00) for the biennial renewal period for which
reinstatement is sought. (For Retired and Retired-Paid, please see N.J.A.C. 13:40-6.1(a)(8)(i) and
(ii).
d. Submit payment of an inactive license fee ($80.00).
e. Submit proof of having completed required continuing education credits.
Pursuant to N.J.S.A. 45:1-7.4(e), if a board review of an application for reinstatement or reactivation establishes
a basis for concluding that there may be practice deciencies in need of remediation prior to reinstatement
or reactivation, the board may require the applicant to submit to and successfully pass an examination or an
assessment of skills, a refresher course, or other requirements as determined by the board prior to reinstatement
or reactivation.
Please note: you must possess an active New Jersey license in order to practice engineering and/or land
surveying, including but not limited to, signing and sealing documents. Signing and sealing documents without
an active license may be considered the unlicensed practice of the profession and may result in disciplinary
action.
Please submit all of the above-referenced documents to:
New Jersey State Board of Professional Engineers and Land Surveyors
124 Halsey Street, 3rd Floor
P.O. Box 45015
Newark, New Jersey 07101
Proof
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Application for Reinstatement or Reactivation
You may not practice in the State of New Jersey until your license is in an active status.
Please select the status your license is currently in: Suspended Inactive Retired or Retired-Paid
N.J. License/Certicate No.:__________________________ Initial License/Certicate Date: __________________________
Year of last renewal: _______________
This application must be completed and accompanied by the enclosures noted on the instruction sheet and the total fee noted
on the enclosed invoice.
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.
Section I
Personal Information Date of birth: ________________________
Month Day Year
1. Name _________________________________________________________________________________________________
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.
Proof
3. *SocialSecurityNo:____-____-____
*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
isrequiredtoobtainyourSocialSecuritynumber.Pursuantto theseauthorities,theBoard isalsoobligatedtoprovide
yourSocialSecuritynumberto:

a. the Director ofTaxation 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 qualified aliens.To comply with this federal law, check the appropriate box below which indicates your
citizenship/immigrationstatus.IfyouarenotaU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)or
otherdocumentationissuedbytheofceofU.S.CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questions about your immigration status and whether or not it is a qualifying status under federal law should be
directedtotheUSCISat:1-800-375-5283.
5. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the
entity that issued your student loan, for the eventual repayment of the loan.You will not be able to obtain
 alicenseorcerticateunlessyouprovidetherequireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. ChildSupport
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation?
Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2) If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths?
Yes No
b.
Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths?
Yes No
c.
Haveyou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reinstatement/reactivation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
Indicatebelow(bycheckingtheappropriatebox)thetypeofpracticewithwhichyouwereinvolvedoremployedbypriorto
yourlicenseexpiringorbeingsuspendedbytheBoard.
Proprietorship Corporation Partnership  ProfessionalServiceCorp.
Ifyouwereself-employedandusedabusinessaddressotherthanyourhome,completethefollowing:
Businessname:______________________________________________________________________________________________
Businessaddress:____________________________________________________________________________________________
 
Street
____________________________________________________________________________________________________________
 City State ZIPcode
click to sign
signature
click to edit
Proof
Section III
Provide the requested information for every position held, since the last biennial period during which your license/certicate
was in active status.
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Immediate Supervisor’s name: _________________________________________________________________________________
Immediate Supervisor’s address: _______________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Employer’s title or position: ___________________________________________________________________________________
Employer’s telephone number:_____________________________ Immediate Supervisor’s telephone number: ____________________________
(Include area code) (Include area code)
Dates employed: from: __________________________ to: __________________________
month day year month day year
Character of engagement. Describe and distinguish design work and other engineering or land-surveying work and
specific projects explicitly in outlined statements; include the complexity of the work and duties and the degree
of responsibility, and also state the time spent in design and other engineering or land-surveying work for each engagement.
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Immediate Supervisor’s name: _________________________________________________________________________________
Immediate Supervisor’s address: _______________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Employer’s title or position: ___________________________________________________________________________________
Employer’s telephone number:_____________________________ Immediate Supervisor’s telephone number: ____________________________
(Include area code) (Include area code)
Dates employed: from: __________________________ to: __________________________
month day year month day year
Character of engagement. Describe and distinguish design work and other engineering or land-surveying work and
specific projects explicitly in outlined statements; include the complexity of the work and duties and the degree
of responsibility, and also state the time spent in design and other engineering or land-surveying work for each engagement.
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
Section II
Information Regarding Practice During Period of Suspended/Expired Licensure
Were you engaged in the practice of your profession or occupation in New Jersey during the period that your New Jersey license
was not in an active status? Yes No
If “Yes,” please provide a description of work performed or a list of projects signed and sealed during the lapsed period along
with the corresponding date of signature. You may use additional sheets of paper if necessary.
Description/Project Date Signed and Sealed
1
2
3
4
5
6
7
8
Proof
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Immediate Supervisor’s name: _________________________________________________________________________________
Immediate Supervisor’s address: _______________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Employer’s title or position: ___________________________________________________________________________________
Employer’s telephone number:_____________________________ Immediate Supervisor’s telephone number: ____________________________
(Include area code) (Include area code)
Dates employed: from: __________________________ to: __________________________
month day year month day year
Character of engagement. Describe and distinguish design work and other engineering or land-surveying work and
specific projects explicitly in outlined statements; include the complexity of the work and duties and the degree
of responsibility, and also state the time spent in design and other engineering or land-surveying work for each engagement.
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
Employer’s name: ____________________________________________________________________________________________
Employer’s address: __________________________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Immediate Supervisor’s name: _________________________________________________________________________________
Immediate Supervisor’s address: _______________________________________________________________________________
Street
___________________________________________________________________________________________________________
City State ZIP code
Employer’s title or position: ___________________________________________________________________________________
Employer’s telephone number:_____________________________ Immediate Supervisor’s telephone number: ____________________________
(Include area code) (Include area code)
Dates employed: from: __________________________ to: __________________________
month day year month day year
Character of engagement. Describe and distinguish design work and other engineering or land-surveying work and
specific projects explicitly in outlined statements; include the complexity of the work and duties and the degree
of responsibility, and also state the time spent in design and other engineering or land-surveying work for each engagement.
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________
You may use addtional copies of this page if necessary.
Proof
Section IV
Please provide below a detailed explanation for your failure to renew promptly.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Section V
Answer all of the following questions as they pertain to the time period since you were last licensed or certied in New Jersey.
1. Since your last renewal have you been arrested, charged or convicted of any crime or offense that you have not
already reported to your board/committee? (Minor trafc offenses, such as speeding or parking, need not be provided
but motor vehicle offenses such as driving while impaired or intoxicated must be disclosed.) Yes No
2. Since your last renewal has any action been taken or is any action now pending against your professional license or
have you been permitted to surrender or otherwise relinquish your license to avoid inquiry, investigation or
action by any other licensing authority that you have not already reported to your board/committee? Yes No
3. Have you completed the continuing education units as required as part of the reinstatement/reactivation of your license?
If you answered “Yes,” please attach a copy of all of the certicates you have earned to this application. Yes No
4. I am requesting retired license status. Yes No
Pursuant to N.J.S.A. 45:8-36.2, you must meet the following requirements to request retired status:
a) I am 62 years of age or older; Yes No
b) I have been licensed for 25 years or more; and Yes No
c) I agree that I shall not offer/practice professional engineering or land surveying in the State of New Jersey while
in retired license status. Yes No
The fee for a retired license is $40.00.
Please Note: If you have answered “Yes” to questions 1 or 2 above, you must provide an explanation and attach any and
all related documents to this application.
Proof
Section VI
1. Do you currently hold, or have you ever held, a professional license or certicate (other than your New Jersey
license as a professional engineer or land surveyor) 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 dates(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
2. 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
3. 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
4. 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
5. Have you ever been named as a defendant in any litigation related to the practice of engineering, land surveying or other
professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
6. 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
7. 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
8. 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 engineering, land surveying 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 2 through 8, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Proof
Section VII
CertifiCation for reinstatement/reaCtivation appliCation
I, ________________________________________________ , in making this application to the Board or Committee for
reinstatement /reactivation of certification 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 reinstatement/reactivation 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 reinstatement/reactivation. 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.
_____________________________________________________________ ___________________________________
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Proof 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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