Fillable Temporary Licenses and Training Permits Renewal Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Temporary Licenses and Training Permits Renewal Application (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.

Temporary Licenses and Training Permits Renewal Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 9 minutes to complete

The Temporary Licenses and Training Permits Renewal Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 2 pages long and contains:

  • 2 signatures
  • 4 check-boxes
  • 25 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 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
Temporary Licenses and Training Permits Renewal Application
Date:_____________________________
Pleaseencloseanonrefundableapplicationlingfeeof$20.00intheformofacheckormoneyordermadeouttotheState
ofNewJersey.
Applicant’sname:____________________________________________________________________________________
LastnameFirstnameMiddleinitial
Nameofsponsor:___________________________________________________________________________________
LastnameFirstnameMiddleinitial
Nameofbusiness:____________________________________________________________________________________
Businessaddress:_____________________________________________________________________________________
Street City State ZIPcode County
Businesstelephonenumber:______________________________________

(includeareacode)
Please renew this permit pursuant to N.J.S.A. 45:9A-16b and N.J.A.C. 13:35-8.1 through 8.17.
Applicant’ssignature:____________________________________________Date:_______________________________
Sponsor’ssignature:_____________________________________________Date:_______________________________
(For Ofce Use Only)
Certied check/Money order: $ ______________.
Training Permit number: ___________________ is renewed.
The new expiration date is __________________.
IMPORTANT
If you are changing sponsor and/or location, enclosed is a Sponsor’s Afdavit form which must be completed
and returned to the above address.
DO NOT MAIL SPONSOR’S AFFIDAVIT IF SPONSOR HAS NOT CHANGED.
click to sign
signature
click to edit
click to sign
signature
click to edit

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 FULLTIME PARTTIME* 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
AfxSealHere
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

Temporary Licenses and Training Permits Renewal Application (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