Fillable Sponsors Afdavit Hearing Aid Dispensers Examining Committee (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Sponsors Afdavit Hearing Aid Dispensers Examining Committee (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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

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
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
140 East Front Street, 3rd Floor, P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Hearing Aid Dispensers Examining Committee
Sponsor’s Afdavit
Please complete and return this afdavit with the completed application.
IherebyafrmthatIamcurrentlylicensedandregisteredtopracticehearingaiddispensinginNewJersey.Ihavebeenactively
practicinginNewJerseycontinuouslysince_____________.PursuanttoN.J.S.A.45:9A-16b,N.J.A.C.13:35-8.3andN.J.A.C.
13:35-8.6, I hereby agree to assume full responsibility for the supervision and training of _____________________________
uponreceiptofaTrainingPermit,intherequisiteskills,methodsandtechniquessoastoinsurecompetencyinthettingand
dispensingofhearingaids.Theapplicantwilltrain FULLTIME PARTTIME*atmybusinesslocation. Iwillassume
fullresponsibilityforandguaranteethetrainee’sactivitiesintheselling,testing,ttinganddispensingofthehearingaids.
PursuanttoN.J.S.A.45:9A-16aandN.J.A.C.13:35-8.5and8.6,Iwillassumefullresponsibilityforandguaranteethetemporary
licenseof_____________________________andhis/hersupervision,trainingandactivitiesintheselling,ttinganddispensingof
hearingaids.
_______________________________________________________ _________________________________

BusinessName Telephonenumber(includeareacode)
________________________________________________________________________________________________________

 StreetAddress  City State ZipCode
Therm’sSupervisingLicensee’sname(N.J.A.C.13:35-8.8)
_______________________________________________________ ________________________________

Name Licensenumber
Thesponsormustenclosecopiesofhis/heroriginalN.I.H.I.S.certicatesindicatingthecompletionofaminimumof20continuing
educationcoursehoursduringthePREVIOUSBIENNIALREGISTRATIONPERIOD.
____________________________________________________ ______________________________________________

Sponsor’sSignature Date LicenseNumber
Swornandsubscribedtobeforemethis
dayof__________________________ ,_____________
MonthYear
______________________________________________

NameofNotaryPublic(pleaseprint)
______________________________________________

SignatureofNotaryPublic
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Sponsors Afdavit Hearing Aid Dispensers Examining Committee (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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