Fill - Free fillable Reinstatement Application for a Certicate of Authorization (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) PDF form

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

New Jersey State Board of Architects

124 Halsey Street, 3rd oor, P.O. Box 45001

Newark, New Jersey 07101

(973) 504-6385

Reinstatement Application for a Certicate of Authorization

Required pursuant to the provisions of N.J.S.A. 13:27-4.9

Period from: 03/03/2018 Period to: 1/31/2020 Certicate No. 21AC _____________________________

Reinstatement fee: $800.00 - Make your check or money order payable to the New Jersey State Board of Architects and

return to: New Jersey State Board of Architects, P.O. Box 45001, Newark, NJ 07101.

Business name Telephone no. (include area code)

Business address

Complete this section only if your name or address is different from that printed above.

(You must include a copy of legal documentation for a name change.)

Business name Telephone no. (include area code)

Business address

Print name of responsible architect

Please submit a copy of the current annual report led with the Division of Revenue in the New Jersey Department of Treasury

with this application.

Certication Statement

“I certify that the information entered on this form is true and complete to the best of my knowledge, and further acknowledge

that if the above information is willfully false, I am subject to punishment and/or disciplinary sanction including license or

certication suspension/revocation or the imposition of civil penalties as may be provided by law.”

Signature of licensee (Responsible architect) Date

Print name of licensee (Responsible architect) Business telephone no. (include area code)

Print full license number of licensee (Responsible architect) E-mail address

 21AI

If the principal’s name has changed (responsible architect), check this box to receive a new wall certicate.

Details of ownership

Complete this page if there have been any changes in the structure of the company since

the last submission to the New Jersey State Board of Architects.

Designation:* D = Director M = Manager or Member O = Ofcer

P = Principal Stockholder A = All designations

Please specify if more than one designation is applicable.

Name and address (and title if any) *Desig. Number of shares

of each ofcer, director, manager

and principal stockholders. Owned Percent New Jersey license number Signature

Use an additional sheet of paper if necessary.

Total shares issued Issued: ____________________

and outstanding. Outstanding: _______________

I certify that I am familiar with the

laws and regulations governing the

practice of architecture in New

Je rs ey. I a m aware t h a t th e

Certicate of Authorization may be

revoked if any agent, employee,

director or ofcer of the corporation

or manager or member of a limited

liability company violates or causes

to be violated any provisions of those

laws or regulations.

RA _________________ PP ________________