Fillable Reinstatement or Reactivation of Advanced Practice Nurse Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Reinstatement or Reactivation of Advanced Practice Nurse Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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The Reinstatement or Reactivation of Advanced Practice Nurse Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 18 pages long and contains:

  • 7 signatures
  • 59 check-boxes
  • 205 other fields

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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
Instructions for Completing the Application for
Reinstatement or Reactivation of Advanced Practice Nurse Certication
Please be advised that under the New Jersey Uniform Enforcement Act (N.J.S.A. 45:1-7.1(b)), a license shall
be suspended 30 days following the expiration date. A license may be reinstated provided that the applicant
otherwise qualies for licensure, and complies with the provisions of N.J.S.A. 45:1-7.4.
1. Reinstatement:
a. Submit a completed application.
b. Submit a signed and dated certication of employment listing each job held during the period of
suspended license, which includes the names, addresses, and telephone numbers of each
employer.
c. Submit payment of the renewal fee ($160.00) for the biennial renewal period for which
reinstatement is sought.
d. Submit payment of the unpaid renewal fee ($160.00) for the biennial period immediately
preceding the renewal period for which reinstatement is sought, if unpaid.
e. Submit payment of a reinstatement fee ($100.00).
f. Submit proof of having completed required continuing education credits for renewal of a
registered nurse license.
g. Submit the Certication and Authorization form for a criminal history background check with
the appropriate fee (please see the attached form for the current fee).
h. Submit proof of having current certication by your national certifying agency.
2. Reactivation:
a. Submit a completed application.
b. Submit a signed and dated certication of employment listing each job held during the period of
suspended license, which includes the names, addresses, and telephone numbers of each
employer.
c. Submit payment of the renewal fee ($160.00) for the biennial renewal period for which
reactivation is sought.
d. Submit proof of having completed required continuing education credits for renewal of a
registered nurse license.
e. Submit the Certication and Authorization form for a criminal history background check with
the appropriate fee (please see the attached form for the current fee).
f. Submit proof of having current certication by your national certifying agency.
Pursuant to N.J.S.A. 45:1-7.4(e), if a board review of an application for reinstatement or reactivation establishes
a basis for concluding that there may be practice deciencies in need of remediation prior to reinstatement
or reactivation, the board may require the applicant to submit to and successfully pass an examination or an
assessment of skills, a refresher course, or other requirements as determined by the board prior to reinstatement
or reactivation.
Please submit all of the above-referenced documents to:
New Jersey State Board of Nursing
124 Halsey Street, 6th Floor
P.O. Box 45010
Newark, New Jersey 07101
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
Application to Reinstate or Reactivate Advanced Practice Nurse Certication
Reinstate Reactivate
Along with the submission of this completed application, all fees must be paid in the form of a check or money order made
out to the State of New Jersey. The fee(s) must be submitted with this application (applicants should understand that if the fee is
paid with a personal check, and the check is returned by the bank due to insufcient funds, the next step in the reinstatement
process will be delayed until the fee is paid).
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application (including your address of record) 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: ________________________
Month Day Year
1. Name _________________________________________________________________________________________________
Last name First name Middle name 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
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.
_______________________
A.P.N. License Number
_______________________
Area of Clinical Specialty
3. *Social Security No: ____ - ____ - ____
You must provide your Social Security number to the Board. Failure to do so will result in denial of licensure reinstatement.
*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
is required to obtain your Social Security number. Pursuant to these authorities, the Board 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. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses, registrations 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 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. 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 questions a(1) through d will result in a denial of
reinstatement of licensure. 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.
_________________________________ __________________________________________ ___________________
Applicant’s name (please print) Applicant’s signature Date
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signature
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6. Illegal Use of Controlled Dangerous Substances
The question below pertains to the illegal use of controlled dangerous 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 this question 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 application. 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 on the Fifth
Amendment, provided that the Attorney General rst grants you immunity afforded by statutory law, (N.J.S.A. 45:1-20).
“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 365 days, whichever is longer.
“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. Are you currently engaged in the illegal use of controlled dangerous substances? (As stated above, “currently” is dened as
“recently enough… [to] have an ongoing impact…” or “within the previous 365 days,” whichever is longer.)
Yes No
If you answered “Yes,” are you currently participating in a supervised rehabilitation program or professional assistance program
that monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substances?
Yes No
_____________________________________________________ ___________________________________
Applicant’s signature Date
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signature
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7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
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 or certicate 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 or certicate 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/expire
11. Have you ever been disciplined or denied a nursing 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 certication 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 nursing 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 nursing 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.
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 Board of 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, 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
__________________________________________________
Afx Seal Here
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
} ss.
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signature
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signature
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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 or Reactivation of a Lapsed License
Directions:Pleasecompletethiscertication,signanddateit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
 R.N. LicenseNo.___________________________
A.P.N. CerticateNo._________________________
Employment Data: (For the past ve (5) years in New Jersey or in any other State.)
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)
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)
3. ______________________________________________________________________

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)
4. ______________________________________________________________________

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. ______________________________________________________________________

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)
_________________________________ ________________________________ ______________________
Applicant’s name (Please print) Applicant’s signature Date
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Continuing Education Compliance Report Form
Name: ______________________________________________________ R.N. License Number: _________________________
I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the
foregoing statements made by me are willfully false, I am subject to punishment, including but not limited to suspension or
revocation of a license and/or certi cation under N.J.S.A. 45:1-21.
Signature: ___________________________________________________________
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
Title of Program
Attach copies of the certifi cates*
Date
Program Provider
Contact
Hours
A total of 30 contact hours is required.
Total
_______
*Attach a copy of the program certifi cate of completion/attendance (usually one page) for each listing noted
above to add up to 30 contact hours. Please refer to N.J.A.C. 13:37-5.3 for information regarding approved C.E.U.
providers. Please note: The required 30 C.E.U.’s must be related to Nursing. (www.NJConsumerAffairs.gov)
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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
Dear Applicant:
In November 2003, legislation was passed that requires the Division of Consumer Affairs to conduct criminal
history record background checks on all health care professionals prior to the issuance of an initial license or
other authorization to practice a health care profession (N.J.S.A. 45: 1-28 et seq.). The records of the Division
show that you are a current applicant for licensure or certication as a health care professional, and as such,
the Division must arrange to conduct a criminal history check of your background.
In order for the Division to conduct a criminal history record background check, you must complete the
enclosed Certication and Authorization form and return it to the mailing address above.
(In-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward your information
about how to schedule an appointment with MorphoTrust, Inc., to have your ngerprints electronically
recorded. A $62.70 ngerprinting fee must be paid to MorphoTrust, at the time of ngerprinting. The
$62.70 payment should be in the form of a check or money order made payable to MorphoTrust.
(Out-of-State Applicants)
Upon receipt of the completed Certication and Authorization form, the Board will forward you one state
and one federal ngerprint card. Out-of-state applicants must have their ngerprints recorded, on the cards
provided, by their local police department, by their state police department or by their local law enforcement
agency. You must return the ngerprint cards to the Board or Committee with the required fee. Applicants
submitting ngerprint cards will be required to pay a $58.69 fee to have their ngerprints scanned into the
electronic system by MorphoTrust. The $58.69 should be in the form of a check or money order made
payable to MorphoTrust.
If you fail to complete and return the Certication and Authorization form, your application for licensure or
certication will not be processed and your application will be considered abandoned.
The New Jersey Board of Nursing
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Nursing
P.O. Box 45010
Newark, New Jersey 07101
(973) 504-6430
CertifiCation and authorization form
for a Criminal history BaCkground CheCk
Directions: Answer all of the questions on this form.
1.
Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs
since November 2003? Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history background process.
Please send no payment now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check
conducted for the Department of Education, another state agency or another state does not apply) you will not be required to
be ngerprinted a second time. However, the Division must perform a criminal history background check each time you apply
for licensure or certication. The fee for this service is $18.75. Payment should be made in the form of a check or money
order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.) Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Mr.
Mrs.
Ms.
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
RN/LPN Reinstatement
CCertifi ation
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the 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 or Committee.
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 or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________
_________________________________
Signature of applicant Date
Rev. 1/2/19
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Reinstatement or Reactivation of Advanced Practice Nurse Certication (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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