Fillable Realtime Court Reporting Examination Application for Authorization to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Realtime Court Reporting Examination Application for Authorization to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Court Reporting
124 Halsey Street, 6th Floor, P.O. Box 45019
Newark, New Jersey 07101
(973) 504-6490
Application for Authorization to Take the
Realtime Court Reporting Examination
Date: _______________________________
A nonrefundable application ling fee of $150, in addition to an examination fee of $100 (for a total of $250), 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.)
The Board maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You may choose
which of these addresses will be considered as your “address of record.” If you do not indicate (by putting a check in the appropriate box)
which address should be used as your address of record, your mailing address will be considered to be your address of record. A post ofce
box may be used as your address of record, but only if you provide another address which includes 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: _________________________
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.
3. SocialSecurityNumber
IfyouwereissuedaSocialSecurityNumberoranIndividualTaxpayerIdenticationNumber,youmustprovideittotheBoardor
Committee.Failuretodosomayresultindenialoflicensure/certication/reinstatement/reactivation.
*SocialSecurityNumber: __________-__________-__________
*IndividualTaxpayerIdentication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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thisinformation.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovidethisinformationto:
(For healthcare-related boards, the following a, b and c entries apply. For boards not related to healthcare, only the a and b
entries apply.)
 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 anAmerican citizen, please enclose a copy of your birth certificate or U.S. passport. 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,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeithera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throughdmayresultin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
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 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 of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory
law. (N.J.S.A. 45:1-20.)
“Ability to practice as a Certied Realtime Court Reporter” is to be construed to include all of the following:
a. The cognitive capacity to exercise reasonable realtime court reporter judgments 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 realtime court reporter, 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 treat-
ment (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 as-
sistance 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
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to de-
termine 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
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 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
11. 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
12. 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
13. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any agency
or certication 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 the practice of shorthand, realtime or court reporting 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 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
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 the practice of shorthand, realtime or court reporting 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.
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. What is the name and address of the colleges, universities or business schools you have attended? (Use additional sheets of paper if
necessary.)
Name of college, university or business school
Street address City State ZIP code
Name of college, university or business school
Street address City State ZIP code
5. A) List all of the degrees, diplomas or certicates that you have received from recognized colleges, universities or business schools.
Please have each school forward to the Board the ofcial transcript for each degree, diploma or certicate that you have
earned.
Educational institution Inclusive years Degree, Major Date granted
Diploma or
Certicate
___________________________ _______________ ____________ ___________ _______________________
___________________________ _______________ ____________ ___________ _______________________
6. Please list all of the courses you have taken in court reporting. (Use additional sheets of paper if necessary.) _________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Experience
1. List the experience you have acquired. Provide the information about your current employment rst.
(a) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: _____________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): _____________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
(b) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): _____________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
(c) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name and title: ____________________________________________________________________
Additional Pertinent Information
1. Do you hold a current certicate as a Certied Shorthand Reporter? Yes No
If “Yes,” please submit a copy of your current certicate.
2. Please list your residences for the last ve years in chronological order. Number of year(s)
_______________________________________________________________________________________ _____________
_______________________________________________________________________________________ _____________
_______________________________________________________________________________________ _____________
_______________________________________________________________________________________ _____________
_______________________________________________________________________________________ _____________
Important Information
1. You must be at least 18 years old at the time of the examination in order to qualify.
2. All of the documents needed to be authorized to take the examination must be received no later than 21 days prior to the date of the
examination.
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 Court Reporting for
licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the State Board of Court
Reporting, 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. 45:15B-1 et seq., together with the Rules and Regulations of the State Board of Court
Reporting, N.J.A.C. 13:43-1.1 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 qualifications for licensure or certification. 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
} ss.
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Realtime Court Reporting Examination Application for Authorization to (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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