New Jersey Is an Equal Opportunity Employer. Printed on Recycled Paper and Recyclable
Certification in Support of Application for Temporary
Emergency License for Out-of-State Providers
CERTIFIED HOMEMAKER HOME HEALTH AIDE
I, _______________________________________________________, certify to the following:
Name
1) My home address is _______________________________________________________
2) My contact telephone numbers are ___________________________ (home)
___________________________ (work)
___________________________ (mobile).
3) My email address is _______________________________________________________
4) I hold a current license in good standing issued by the _____________________________
Board
of the state of ________________________________________________, with license number
______________________________, and have practiced as a Homemaker-Home Health Aide
within the last fiv
e years.
5) I have a promise of employment from the following agency _____________________________,
which can be contacted at the following phone number: _______________________________,
and by email at ______________________________.
For informational purposes only
:
6) I intend to treat patients ____ in person; ____ via telemedicine/telehealth (check all that apply)
7) I have the following specialized skills, training, or availability that are relevant during a public
health emergency:
_________________________________________________________________________
_________________________________________________________________________
By checking this box, I certify to truth and accuracy of the above: _____
Please send the completed document to NJTempLicense@dca.njoag.gov. Your application will
be reviewed and responded to within 24 hours.
PRACTITIONERS AUTHORIZED TO PRACTICE BY ACCELERATED TEMPORARY LICENSURE MUST COMPLY WITH ALL
APPLICABLE STATUTES AND RULES.
GO TO YOUR BOARD’S WEBSITE TO VIEW THESE DOCUMENTS.
Division of Consumer Affairs
New Jersey Board of Nursing
124 Halsey Street, 6
th
Floor, Newark NJ 07102
http://www.njconsumeraffairs.gov/nur
PHILIP D. MURPHY
Governor
S
HEILA Y. OLIVER
Lt. Governor
GURBIR S. GREWAL
Attorney General
PAUL R. RODRIGUEZ
Acting Director
Mailing Address:
P.O. Box 45010
Newark, NJ 07101
(973)
504-6430
