Fillable Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide (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.

Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 27 minutes to complete

The Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 7 pages long and contains:

  • 6 signatures
  • 32 check-boxes
  • 70 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
New Jersey Board of Nursing
124 Halsey Street, 6th Floor, P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
www.njconsumeraffairs.gov/nur/Pages/default.aspx
Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide
Please place a check mark next to each category, sign and date this checklist when submitting with
your application.
Name of Applicant: ______________________________________________
Social Security Number: _______ - ________ - ________
____ Review instruction sheet
____ Application for Reinstatement. Answer all questions where indicated. (pages 2, 3)
____ Notarized Afdavit (page 4)
____ Electronic Employer Verication
____ Employment Certication for the Reinstatement of a Lapsed Certication (pages 6, 7)
____ All required fees are included along with a check or money order only (page 15)
ALL QUESTIONS MUST BE FILLED IN WITH THE APPROPRIATE ANSWER OR THE
LETTERS N/A (NOT APPLICABLE). DO NOT LEAVE ANY BLANK ANSWERS OR YOUR
APPLICATION WILL BE RETURNED.
I have completed all of the above items.
Signature________________________________
Date ____________________________________
click to sign
signature
click to edit
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
www.njconsumeraffairs.gov/nur/Pages/default.aspx
Instructions
for Reinstatement of a
Homemaker-Home Health Aide Certication
Please read the following information carefully before completing the application for Homemaker-
Home Health Aide (HHA) certication.
If you have previously taken the 76 hour training, please provide a copy of the letter of completion
from the Training School or Facility that was sent to the Board.
1. Complete an application for HHA Reinstatement Certication. Answer ALL of the
questions.
2. Sign the application in the presence of a notary public.
3. Attach a clear, full-face original passport photograph (2” x 2”) of your head and shoulders
taken within the past six months. Sign your name on the front of the picture. (Photocopies
and seles are not acceptable.)
4. If you are a naturalized U.S. citizen, please submit a copy of your U.S. passport or certicate
of naturalization.
5. If you are a legal alien or have other immigration status, please submit your USCIS
immigration documents. (Submit a copy of both the front and the back of your card.)
6. Submit a check or money order for your application and certication fees in the amount of
either $80.00 or $50.00 made payable to the “New Jersey Board of Nursing”- see fee schedule
at the end of the application.
7. Please notify the Board of any change of address or change in your contact information.
8. Pursuant to N.J.A.C. 13:37-14.15(b), an applicant for reinstatement may be required to
submit to a skills assessment if the Board determines that there may be practice deciencies
upon review of the application.
- 1 -
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
www.njconsumeraffairs.gov/nur/Pages/default.aspx
Application for Reinstatement of a Homemaker-Home Health Aide Certicate
You may not practice in the State of New Jersey until your
Homemaker-Home Health Aide Certicate is Reinstated.
- 2 -
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months, with your
name printed on the back of the
photo.
A photo is required with each
application.
Do not use staples to attach the
photo.
Please print in black or blue ink only. This application must be completed, notarized and returned to the New
Jersey Board of Nursing with your reinstatement fee payable by check or money order. The certication fee
is refundable. Information that you provide on this application may be subject to public disclosure as required
by the Open Public Records Act (OPRA).
Complete the following information:
Full Name ______________________________________________________________________________
Address ________________________________________________________________________________
City, State, ZIP __________________________________________________________________________
Telephone number(s) ___________________________ _____________________________________
(Home) (Work)
Date of Birth __ __ /__ __ /__ __ Certicate number _____________________________________
Month Day Year
E-mail address ___________________________________________
Have you changed your name since you were last certied? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
Social Security Number
You must provide 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)A of 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.
- 3 -
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.
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. 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
Please answer ALL of the questions below as they apply to the period of time since you were last certied or
for the period of time since you last applied for reinstatement.
1. Have you been convicted of a crime? Yes No
2. Are there any criminal charges against you now pending? Yes No
(Parking or speeding violations do not require you to answer
“Yes,” but all other motor vehicle offenses must be disclosed.)
3. Has your professional license been revoked or suspended Yes No
(whether active or stayed) by any licensing board?
4. Is any action now pending against your professional license or Yes No
have you been permitted to surrender or otherwise relinquish
your license to avoid inquiry, investigation or action by any
state licensing board?
click to sign
signature
click to edit
- 4 -
Afx Seal Here
}
ss.
AffidAvit
Please identify any person other than the applicant who helped to prepare this form:
____________________________ ___________ ______________________________
Name (print) Date Signature
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 Board of Nursing
for certication or licensure 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 certication or licensure or to withhold renewal of
or suspend or revoke a certicate or license 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, and fully understand that in receiving certication or licensure 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 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.
Sworn and subscribed to before me this _________
day of _______________________ , __________
Month Year
_________________________________________
Name of Notary Public (please print)
________________________________________________________________________ __________________________________________________
Signature of Notary Public My Commossion Expires
Ofcial Use Only - Do Not Write Below The Line Candidate number ________________________
Certicate number _______________________
click to sign
signature
click to edit
click to sign
signature
click to edit
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
www.NJConsumerAffairs.gov/nursing
Employment Certication for the Reinstatement of a Lapsed Certication
Directions: Please complete this certication. Have it notarized and return it to the New Jersey
Board of Nursing. If you have had more than two employers, please add additional sheets of paper
with the employment data. The Board may contact your employer(s) to verify your employment.
____________________________________________________________________________
First name Middle name Last name Maiden name
____________________________________________________________________________
Present Street Address City State ZIP Code
C.H.H.A. Certicate No. ___________________________ .
Employment Data: (For the past ve (5) years in New Jersey or in any other jurisdiction.)
1. _________________________________________________________________________
Name of employing agency or facility
_________________________________________________________________________
Street address
_________________________________________________________________________
City State ZIP Code
_________________________________________________________________________
Job Title Employment Dates: From To
_________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
- 5 -
2. _________________________________________________________________________
Name of employing agency or facility
_________________________________________________________________________
Street address
_________________________________________________________________________
City State ZIP Code
_________________________________________________________________________
Job Title Employment Dates: From To
_________________________________________________________________________
Supervisor’s name Title Telephone No. (include area code)
The person whose signature appears below personally appeared before me and, being duly
sworn, says that he/she is the person referred to in the foregoing Employment Certication. The
home health aide further attests that he/she has read and understands this certication and that
all of the information contained herein is provided completely and truthfully to the best of his/her
knowledge and beliefs.
____________________________________
Signature of applicant
Sworn and subscribed to before me this _________
day of _______________________ , ___________
Month Year
_________________________________________
Name of Notary Public (please print)
_________________________________________ _______________________________
Signature of Notary Public My Commission Expires
Afx Seal Here
- 6 -
click to sign
signature
click to edit
click to sign
signature
click to edit
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
www.njconsumeraffairs.gov/nur/Pages/default.aspx
Homemaker-Home Health Aide
Reinstatement Application Fee Schedule
- 7 -
Type of Fee
,I\RXUOLFHQVHH[SLUHGbefore:
November
If your license expired on
or after: November 30, 201
Current 2-year renewal fee $ 30.00 $ 30.00
Original License Issued In An
Odd-Numbered Year
Previous 2-year renewal fee $ 30.00 0
if unpaid
Reinstatement fee $ 20.00 $ 20.00
Total $ 80.00 $ 50.00
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

Reinstatement Applicant Checklist - Certied Homemaker-Home Health Aide (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