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Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to
U.S. citizens or qualified 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
copyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheoceofU.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.
Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Ye s No
(1) If “Yes,” are you in arrears in payment of said obligation? Ye s No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?
Ye s No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months?
Ye s No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding?
Ye s No
d. Are you the subject of a child-support-related arrest warrant? Ye s 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
willresultinadenialoflicensureorcertication.Furthermore,anyfalsecerticationoftheabovemay
subject you to a penalty, including, but not limited to, immediate revocation or suspension of licensure or
certication.
______________________________ ______________________________ _______________
Applicant’s name (please print) Applicant’s signature Date
Please answer ALLofthequestionsbelowastheyapplytotheperiodoftimesinceyouwerelastcertiedor
for the period of time since you last applied for reinstatement.
1. Have you ever received a criminal summons, been arrested, taken Yes No
into custody, indicted, charged, tried by a judge or jury, conditionally
discharged or admitted into pretrial intervention (PTI) for, or pled guilty
to, any violation of law, ordinance, felony, misdemeanor or disorderly
personsoense,inNewJersey,anyotherstate,theDistrictofColumbia
or any other jurisdiction?
2. Have you been convicted of a crime? Yes No
3. Are there any criminal charges against you now pending? Yes No
(Parking or speeding violations do not require you to answer
“Yes,”butallothermotorvehicleoensesmustbedisclosed.)
4. Has your professional license been revoked or suspended Yes No
(whether active or stayed) by any licensing board?
5. Is any action now pending against your professional license or Yes No
have you been permitted to surrender or otherwise relinquish
your license to avoid inquiry, investigation or action by any
state licensing board?