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Request for Upgrade from (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Request for Upgrade from
Planner-in-Training to Professional Planner
The statutes establishing licensure of the practice of Professional Planning, N.J.S.A. 45:14A-1 et seq.,
dene such practice as, “...the administration, advising, consultation or performance of professional work
in the development of master plans in accordance with the provisions of chapter 27 and 55 of Title 40
of the Revised Statutes, as amended and supplemented; and other professional planning services related
thereto intended primarily to guide governmental policy for the assurance of the orderly and co-ordinated
development of municipal, county, regional and metropolitan land areas, and the State or portions thereof.”
To upgrade from a planner-in-training to a licensed professional planner, you must submit the following:
1) An upgrade form (see attached) demonstrating the required work experience as set forth in N.J.A.C.
13:41-5.3(a); or
2) Transcripts verifying that the planner-in-training has completed the required educational experience
as set forth in N.J.A.C. 13:41-5.3(a)2.
Your experience must conform to one or more elements of the practice of professional planning as dened
in the statute. You should be specic so as to minimize the possibility of misinterpretation.
In addition to the details of your experience, furnish the name, address and the professional-planning
position of the person to whom you reported in each engagement. Please show start and end dates for each
engagement by month and year. A minimum of 32 hours per week is considered full-time employment.
Since only half-credit is given for part-time employment, it is important to document accurately the hours
worked per week. You may attach additional sheets if necessary.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Planners
124 Halsey Street, 3rd Floor, P.O. Box 45016
Newark, New Jersey 07101
(973) 504-6465
Request for Upgrade from Planner-in-Training to Professional Planner
Date: _____________________________
Along with the submission of this completed application, the nonrefundable application ling fee must be paid in the form of a
check or money order made payable to the State of New Jersey. The fee is $130.00 in the rst year of the current biennial period
of licensure, or $65.00 in the second year. Please call the telephone number above to learn which year of the biennial licensure
period the Board is in. (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 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. You are, however, 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 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 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
3. Social Security Number
You must disclose your Social Security number for the reasons stated below. Failure to do so may result in a denial of licensure or
certication or license or certicate renewal.
*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 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; and
b. the Probation Division or any other agency responsible for child-support enforcement, upon request.
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 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
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 may 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 your licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
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7. 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
Yes No
8. 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.
explanation. (Attach additional sheets of paper to this application.)
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
9. Have you previously applied for a license or certicate as a professional planner in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
If “Yes,” when and where? _________________________________________________________________
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.
Is this license or
certicate active?
_________________ ___________________ ___________________________ _________________ Yes No
State that issued the license or certicate Date issuedType of license / certicate Number
_________________ ___________________ ___________________________ _________________ Yes No
State that issued the license or certicate Date issuedType of license / certicate Number
_________________ ___________________ ___________________________ _________________ Yes No
State that issued the license or certicate Date issuedType of license / certicate Number
_________________ ___________________ ___________________________ _________________ Yes No
State that issued the license or certicate Date issuedType of license / certicate Number
_________________ ___________________ ___________________________ _________________ Yes No
Number State that issued the license or certicate Date issuedType of license / certicate
11. Have you ever been disciplined or denied a professional planner’s license or certicate or any other professional license or certicate
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 professional planning 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 any 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 professional planning 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.
__________________________________________________________________
Middle initialLast name First name
Engagement number
Date
Month / Year
From - To
Description of Experience
For each engagement, list work experience in chronological order starting with the rst
position held by the applicant in the following formal:
a) The title of your position.
b) The name and address of your employer.
c) The name, address and license number of your immediate supervisor. (If your supervisor
was not a licensed professional planner, then you must also furnish the name of the
licensed professional planner under whose supervision you were employed for each
engagement.)
d) The character of the engagement. Describe the design work and other planning work
and specic projects explicitly in outlined statements. Include a description of the
complexity of the work, the duties and degree or responsibility, and also state the time
spent in design and other planning work for each engagement.
Professional Planning Experience
(This experience must have been acquired
while under licensed supervision.)
Hours
per week
Years Months
Do not
write
in this
space.
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 Professional Planners
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
Professional Planners, 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 affirm) that I have read N.J.S.A. 45:14A-1 et seq., together with the Rules and Regulations of the
State Board of Professional Planners, N.J.A.C. 13:41-1.1 through 13:41-6.1, 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
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
Afx Seal Here
} ss.
Qualications: Recommendations: Board Action:
Education Interview Interview Date ______________________
Experience Admit Exam Withhold/Deny Date ______________________
Examination Certify Certify Date ______________________
Certicate or License No. _____________________________ Granted ___________________________________
For ofce use only:
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Request for Upgrade from (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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