Fillable Registration of Bona Fide Representative (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Registration of Bona Fide Representative (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Registration of Bona Fide Representative (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 10 minutes to complete

The Registration of Bona Fide Representative (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 3 pages long and contains:

  • 2 signatures
  • 6 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

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

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Examiners of Heating, Ventilating,
Air Conditioning and Refrigeration (HVACR) Contractors
124 Halsey Street, 6th Floor, P.O. Box 47031
Newark, New Jersey 07101
(973) 504-6420
Registration of Bona Fide Representative
Select category: Initial submission Change to business
Licensenumber:___________________________
Licensed Master HVACR Contractor
Name:______________________________________________________________________________________
Lastname  Firstname Middlename
Addressofrecord:____________________________________________________________________________
(Availabletothepublic)Streetaddress City State ZIPcode
HomeAddress:______________________________________________________________________________
Streetaddress City State ZIPcode
Hometelephonenumber:_____________________________Cellularnumber:____________________________

(includeareacode) (includeareacode)
Emailaddress:________________________________________________________________________________
MailingAddress:______________________________________________________________________________
Streetaddress City State ZIPcode
HVACR Business
BusinessName:______________________________________________________________________________
NewJerseyBusinessAddress:___________________________________________________________________
Streetaddress City State ZIPcode
IfyoudonothaveaNewJerseyaddress,pleaseidentifytheNewJerseyagentforserviceofprocesspursuantto
N.J.A.C.13:32A-5.3(a)6.
Businesstelephonenumber:_____________________________Faxnumber:_____________________________

(includeareacode) (includeareacode)
In order to register as a bona de representative, you must be a licensed Master HVACR Contractor who
(Select category):
Inthecaseofasoleproprietorship,istheownerofthebusiness;
Inthecaseofapartnership,isapartnerinthebusiness;
Inthecaseofalimitedliabilitycompany,isamanager;or
Inthecaseofacorporation,isanexecutiveofcer.
Name the Ofcers(s) of Record for Corporation (if applicable):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
N.J.A.C. 13:32A-5.2 (a)2 Bona Fide Representative; Reporting Responsibilities requiresproofthattheHVACR
businesshasconsentedthatthebonaderepresentativewillactastheagentforserviceofprocesswithinthisState.
Signatureoflicensee_______________________________
N.J.A.C. 13:32A-5.2 (a)3 Bona Fide Representative; Reporting Responsibilities requiresproofoftheacceptance
ofliabilitybytheHVACRbusinessforanymonetarypenalty,moniestobepaidforrestorationtoconsumersoffees
paidforservicesorfordelayssufferedbyconsumersandcostsassessedagainstthebonaderepresentative,while
actingwithinthescopeofhisorheremploymentonbehalfoftheHVACRbusiness.
Signatureoflicensee_______________________________
-2-
AFFIDAVIT
Thisafdavitistobeexecutedbythelicenseebeforeanotarypublic:
Stateof:_____________________________
Countyof:___________________________
I,_________________________________________________________________________________________,
(LicensedMasterHVACRContractor)
in submitting this registration to the State Board of Examiners of Heating, Ventilating, Air Conditioning and
Refrigeration(HVACR) Contractors undertheprovisionsofTitle 45 oftheGeneralStatutesofNewJerseyand
theRulesoftheStateBoardofExaminersofHeating,Ventilating,AirConditioningandRefrigeration(HVACR)
Contractors,doswearorafrmthatIamthelicensee,andthatalloftheinformationprovidedinconnectionwiththis
registration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registration.
Ifurtherswear or afrmthatIhave read N.J.S.A.45:16A-1etseq. together with theRulesand Regulations of
theStateBoardofExaminersofHeating,Ventilating,AirConditioningandRefrigeration(HVACR)Contractors,
N.J.A.C.13:32A,andfullyunderstandthatinregisteringasabonaderepresentative,Ibindmyselftobegoverned
bythem.
Ifurtherauthorizeallinstitutions,employers,agenciesandallgovernmentalagencies,includingfederal,stateor
localgovernment,toreleaseanyinformationasrequestedbytheBoard.Imayberequiredatanytimetoprovidetax
documentationuponBoardrequest.
______________________________________

Signatureoflicensee
Swornandsubscribedtobeforemethis_____
dayof________________________20____

monthyear
_____________________________________

NameofNotaryPublic(pleaseprint)
_____________________________________

SignatureofNotaryPublic
-3-
} ss.
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Registration of Bona Fide Representative (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document