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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  • 18 check-boxes
  • 16 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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Proof
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
Re-Exam Application for Nurse Licensure by Examination - U.S. Graduates
Please check the license for which you are applying:
Registered Professional Nurse Licensed Practical Nurse
Date:_______________________________
Mr.
1. Name Mrs.________________________________________________________________ (_______________________)
Ms.
Lastname Firstname Middleinitial Maidenname
2. Address________________________________________________________________________________________________
StreetorP.O.Box CityState ZIPcode County
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. HaveyouregisteredforPearsonVue? Yes No(If“No”,youwillnotbeabletoproceeduntilregistrationiscomplete)
5. Hasanythingchangedsinceyourlastapplicationregarding:
Citizenship/Immigrationstatus? Yes No
ChildSupport? Yes No
MedicalCondition? Yes No
Name? Yes No
CriminalHistory? Yes No
Reasonable Testing Accommodations for Individuals with Disabilities. (Check if applicable)
 Ihavebeendiagnosedashavingadisabilityandrequirespecialtestingaccommodations.PleasesendmetheRequestforReasonable
TestingAccommodationsForm.IunderstandthatIwillnotbeabletotestuntilIsubmittheappropriatedocumentationandam
approvedtotestwithaccommodations.

Proof
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
Stateof:__________________________________________________
Countyof:________________________________________________
I, ________________________________________________ , in making thisapplication to the New JerseyBoardof Nursing for
licensureorcerticationundertheprovisionsofTitle45oftheGeneralStatutesofNewJerseyandtheRulesoftheNewJerseyBoardof
Nursing,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Board.
Ifurtherswear(orafrm)thatIhavereadN.J.S.A.45:11-23etseq.,togetherwiththeRulesandRegulationsoftheNewJerseyBoard
ofNursing,N.J.A.C.13:37-1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)
Afx Seal Here
__________________________________________________
SignatureofNotaryPublic
} ss.
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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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