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  • New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

    State Board of Psychological Examiners124 Halsey Street, 6th Floor, P.O. Box 45017

    Newark, New Jersey 07101(973) 504-6470

    Dear Applicant:

    Recent legislation required the Division of Consumer Affairs to conduct Criminal History Record Background Checks of all Health Care Professionals prior to the issuance of a license or permit to practice in a health care profession (N.J.S.A. 45:1-25 et seq.). In order for the Division to conduct a Criminal History Record Background Check, you must complete the enclosed Certification and Authorization form and return it to the Board or Committee at the mailing address above.

    Upon receipt of the completed Certification and Authorization form, the Board or Committee will forward to you information you will need to have your fingerprints recorded. The recording of your fingerprints is necessary to conduct the Criminal History Record Background Check.

    Please note that you will be required to pay a $58.69 fee for this service at the time you schedule your appointment. Anticipate a minimal wait of four to five weeks before your permit is approved or a license is issued.

    Sincerely,

    State Board of Psychological Examiners

    J. Michael Walker Executive Director

  • New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

    State Board of Psychological Examiners124 Halsey Street, 6th Floor, P.O. Box 45017

    Newark, New Jersey 07101(973) 504-6470

    Application for Licensure as a Practicing Psychologist

    Date:____________________________

    Anonrefundableapplicationfilingfeeof$125,intheformofacheckormoneyordermadeouttotheStateofNewJersey,mustbesubmittedwiththisapplication.(Applicantsshouldunderstandthatiftheapplicationfilingfeeispaidwithapersonalcheck,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeeispaid.)

    TheDivisionisprecludedbylawfromdisclosingtothepublictheplaceofresidenceoflicenseesorapplicants,without theirconsent.However,you are requiredtoprovideanaddressthatmaybereleasedtothepublicinour directories orinresponsetootherrequests(byputtingacheckintheappropriatebox). Ifyouprovideyourplaceofresidenceasyourpublicaddressofrecord,wewillassumethatyouhaveconsentedtohavethataddressbedisclosed. Ifyoudonotconsenttothedisclosureofyourplaceofresidence,youshouldprovide anaddressofrecordotherthanyour place ofresidencethatmaybereleasedtothepublic.Oneofyouraddressesmustincludeastreet,city,stateandZIPcode.InformationthatyouprovideonthisapplicationmaybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).

    Please print clearly. You must answer all of the questions on this application.

    Personal Information Dateofbirth:_________________________ MonthDayYear

    Dr. Mr.1. Name Mrs.________________________________________________________________ (_______________________) Ms. Lastname Firstname Middleinitial Maidenname

    2. Address

    Home:______________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

    _____________________________________ ___________________________________ Telephonenumber(includeareacode) E-mailaddress

    Business/Practiceaddress:______________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

    ____________________________________________________________________________________________ Street City State ZIPcode County

    Mailing: ____________________________________________________________________________________________ StreetorP.O.Box City State ZIPcode County

    Attachaclear,full-facepassport-stylephotograph(2x2)ofyourheadandshoulders,takenwithinthepastsixmonths.A photo is requiredwith eachapplication.

    Donotuse staples toattach thephoto.

    -1-

  • 3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosomayresultindenial/nonrenewalof licensureorcertification.

    *SocialSecurityNumber: __________ -____________ -___________

    *PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildSupportEnforcementLaw,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

    a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeofreviewing compliancewithStatetaxlawandupdatingandcorrectingtaxrecords;

    b. theProbationDivisionoranyotheragencyresponsibleforchildsupportenforcement,uponrequest;and

    c. theNational PractitionerDataBank and theH.I.P.DataBank,when reporting adverse actions relating to health care professionals.

    4. Citizenship/ImmigrationStatus

    FederallawlimitstheissuanceorrenewalofprofessionaloroccupationallicensesorcertificatestoU.S.citizensorqualifiedaliens. Tocomplywiththisfederallaw,checktheappropriateboxbelowwhichindicatesyourcitizenship/immigrationstatus.Ifyouarenot aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofficeofU.S. CitizenshipandImmigrationServices(USCIS).

    U.S.citizen AlienlawfullyadmittedforpermanentresidenceinU.S. Otherimmigrationstatus

    Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe USCISat:1-800-375-5283.

    5. ChildSupport

    Pleasecertify,underpenaltyofperjury,thefollowing:

    a. Doyoucurrentlyhaveachild-supportobligation? Yes No

    (1)IfYes,areyouinarrearsinpaymentofsaidobligation? Yes No

    (2)IfYes,doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No

    b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No

    c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No

    d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No

    InaccordancewithN.J.S.A.2A:17-56.44d,ananswerofYestoanyofthequestionsa(1)throughdmayresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

    ___________________________________ ___________________________________ ________________________ Applicantsname(pleaseprint) Applicantssignature Date

    -2 -

  • 6. MedicalConditionsQuestions Questionsathroughfpertaintomedicalconditionsanduseofchemicalsubstances.Pleasereadthedefinitionscarefully.Your

    responseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthoseportionsofthefollowingquestionswhichinquireastotheillegaluseofcontrolleddangeroussubstancesoractivityifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisoftheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw.(N.J.S.A.45:1-20.)

    Ability to practice as a psychologististobeconstruedtoincludeallofthefollowing:

    a. Thecognitivecapacitytoexercisethereasonablejudgmentsofapracticingpsychologist,andtolearnandkeepabreastofpro-fessionaldevelopments;and

    b. Theabilitytocommunicatethosejudgmentsandrelatedinformationtoclientsandotherinterestedparties,withorwithouttheuseofaidsordevices,suchasvoiceamplifiers;and

    c. Thephysicalcapabilitytoperformthedutiesofapracticingpsychologist,withorwithouttheuseofaidsordevices,suchascorrectivelensesorhearingaids.

    Medical Conditionincludesphysiological,mentalorpsychologicalconditionsordisorders,suchas,butnotlimitedtoorthopedic,visual,speechandhearingimpairments,cerebralpalsy,epilepsy,musculardystrophy,multiplesclerosis,cancer,heartdisease,diabetes,mentalretardation,emotionalormentalillness,specificlearningdisabilities,H.I.V.disease,tuberculosis,drugaddictionandalcoholism.

    Chemical substanceistobeconstruedtoincludealcohol,drugsormedications,includingthosetakenpursuanttoavalidpre-scriptionforlegitimatemedicalpurposesandinaccordancewiththeprescribersdirection,aswellasthoseusedillegally.

    Currentlydoesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactononesfunctioningasalicensee,orwithintheprevioustwoyears.

    Illegal use of controlled dangerous substance means the use of a controlled dangerous substance obtained illegally (e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

    a. Doyouhaveamedicalconditionwhichinanywayimpairsorlimitsyourabilitytopracticeyourprofessionwithreasonableskillandsafety? Yes No

    b. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseyoureceiveongoingtreat-ment(withorwithoutmedications)orparticipateinamonitoringprogram**?

    Yes No Notapplicablec. Arethelimitationsorimpairmentscausedbyyourmedicalconditionreducedoramelioratedbecauseofthefieldofpractice,

    thesettingormannerinwhichyouhavechosentopractice?

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