New Jersey Office of the Attorney GeneralDivision of Consumer Affairs

State Board of Medical ExaminersHearing Aid Dispensers Examining Committee140 East Front Street, 3rd Floor, P.O. Box 183

Trenton, New Jersey 08625(609) 826-7100

Application for Training Permit

Date:_______________________________

Pleaseencloseanonrefundableapplicationfilingfeeof$50.00,alongwitha$50.00feeforatrainingpermit,intheformofacheckormoneyordermadeout to theState ofNew Jersey. (Applicants should understand that if the fees are paidwith a personal check,andthecheckisreturnedbythebankduetoinsufficientfunds,thenextstepinthelicensureorcertificationprocesswillbedelayeduntilthefeesarepaid.)Youalsowillberequiredtopayacertificationfeeatalaterdate.

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

Informationthatyouprovideonthisapplication(includingyouraddressofrecord)maybesubjecttopublicdisclosureasrequiredbytheOpenPublicRecordsAct(OPRA).

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

Personal Information Dateofbirth:_________________________ MonthDayYear

Placeofbirth:________________________ CityState

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

2. Address

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

_____________________________________ ___________________________________ Telephonenumber(includeareacode) E-mailaddress

Business:____________________________________________________________________________________________ Nameofcompany Telephonenumber(includeareacode)

____________________________________________________________________________________________ Street City State ZIPcode County

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

Photo

#1

Attachthreeclear,full-facepass-port-stylephotographs(2˝x2˝)ofyour head and shoulders, takenwithinthepastsixmonths.Three photographs are requiredwitheachapplication.

Donotuse staples toattach thephotographs. Pho

tos #2

and #

3

3. SocialSecurityNumber YoumustprovideyourSocialSecuritynumbertotheBoardorCommittee.Failuretodosowillresultindenial/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,theBoardorCommitteeisrequiredtoobtainyourSocialSecuritynumber.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovideyourSocialSecuritynumberto:

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

Please certify, under penalty of perjury, the following:

a. Doyoucurrentlyhaveachild-supportobligation? Yes No

(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No

(2)If“Yes,”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,ananswerof“Yes”toanyofthequestionsa(1)throughdwillresult inadenialoflicensureorcertification.Furthermore,anyfalsecertificationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediaterevocationorsuspensionoflicensureorcertification.

___________________________________ ___________________________________ ________________________ Applicant’sname(pleaseprint) Applicant’ssignature Date

6. IllegalUseofControlledDangerousSubstances

Thequestionbelowpertainstotheillegaluseofcontrolleddangeroussubstances.Pleasereadthedefinitionscarefully.Yourresponseswillbetreatedconfidentiallyandretainedseparately.Pleasebeawarethatyouhavetherighttoelectnottoanswerthisquestionifyouhavereasonablecausetobelievethatansweringmayexposeyoutothepossibilityofcriminalprosecution.Inthatevent,youmayasserttheFifthAmendmentprivilegeagainstself-incrimination.AnyclaimofFifthAmendmentprivilegemustbemadeingoodfaith.IfyouchoosetoasserttheFifthAmendment,youmustdosoinwriting.Youmustfullyrespondtoallotherquestionsontheapplication.YourapplicationforlicensureorcertificationwillbeprocessedifyouclaimtheFifthAmendmentprivilegeagainstself-incrimination.Youshouldbeaware,however,thatyoumaylaterbedirectedbytheAttorneyGeneraltoansweraquestionthatyouhaverefusedtoansweronthebasisontheFifthAmendment,providedthattheAttorneyGeneralfirstgrantsyouimmunityaffordedbystatutorylaw,(N.J.S.A.45:1-20).

“Currently”doesnotmeanonthedayof,orevenintheweeksormonthsprecedingthecompletionofthisapplication.Rather,itmeansrecentlyenoughsothattheuseofdrugsmayhaveanongoingimpactonone’sfunctioningasalicensee,orwithintheprevious365days,whicheverislonger.

“Illegal use of controlled dangerous substance”meanstheuseofacontrolleddangeroussubstanceobtainedillegally(e.g.heroinorcocaine)aswellastheuseofcontrolleddangeroussubstanceswhicharenotobtainedpursuanttoavalidprescriptionornottakeninaccordancewiththedirectionsofalicensedhealthcarepractitioner.

a. Areyoucurrentlyengagedintheillegaluseofcontrolleddangeroussubstances?(Asstatedabove,“currently”isdefinedas “recentlyenough…[to]haveanongoingimpact…”or“withintheprevious365days,”whicheverislonger.)

Yes NoIfyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogramthatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?

Yes No

_____________________________________________________ ___________________________________ Applicant’ssignature Date

7. Haveyoueverchangedyourname? Yes NoIf“Yes,”pleasesubmitwiththisapplicationacopyofthemarriagecertificate,divorcedecreeorcourtorder.

8. Have you ever been summoned; arrested; taken into custody; indicted; tried; chargedwith; admitted into pre-trial intervention (P.T.I.);orpledguiltytoanyviolationoflaw,ordinance,felony,misdemeanorordisorderlypersonsoffense,inNewJersey,anyother state,theDistrictofColumbiaorinanyotherjurisdiction?(Parkingorspeedingviolationsneednotbedisclosed,butmotorvehicle violationssuchasdrivingwhileimpairedorintoxicatedmustbe.) Yes No

9. Haveyoueverbeenconvictedofanycrimeoroffenseunderanycircumstances?Thisincludes,butisnotlimitedto,apleaofguilty, nonvult,nolocontendere,nocontest,orafindingofguiltbyajudgeorjury. Yes No

If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a completeexplanation.(Attachadditionalsheetsofpapertothisapplication.)

10. Doyou currently hold, or have you ever held, a professional license, certificate or permit ofany kind inNew Jersey, any otherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes NoIf “Yes,” for each license, certificate or permit held, provide the date(s) held and the number(s). If the license or certificatewasissuedunderadifferentname,pleaseprovidethatname.

LastnameFirstname Middleinitial

_____________________ _______________________ ________________________________ __________________ Typeoflicense,certificateorpermit Number Stateorjurisdictionthatissuedthelicense,certificateorpermit Dateissued/expired

_____________________ _______________________ ________________________________ __________________ Typeoflicense,certificateorpermit Number Stateorjurisdictionthatissuedthelicense,certificateorpermit Dateissued/expired

_____________________ _______________________ ________________________________ __________________ Typeoflicense,certificateorpermit Number Stateorjurisdictionthatissuedthelicense,certificateorpermit Dateissued/expired

_____________________ _______________________ ________________________________ __________________ Typeoflicense,certificateorpermit Number Stateorjurisdictionthatissuedthelicense,certificateorpermit Dateissued/expired

_____________________ _______________________ ________________________________ __________________ Typeoflicense,certificateorpermit Number Stateorjurisdictionthatissuedthelicense,certificateorpermit Dateissued/expired

11. Haveyoueverbeendisciplinedordeniedaprofessionallicense,certificateorpermitofanykindinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

12. Haveyoueverhadaprofessionallicense,certificateorpermitofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

13. Hasanyaction(includingtheassessmentoffinesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyanyagencyorcertificationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

14. Have you ever been named as a defendant in any litigation related to any prior practice as a hearing aid dispenser, or otherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

15. Areyouawareofanyinvestigationpendingagainstaprofessionallicense,certificateorpermitissuedtoyoubyaprofessionalboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

16. Are there any criminal charges nowpending against you inNew Jersey, anyother state, theDistrict ofColumbiaor in anyotherjurisdiction? Yes No

17. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgrouprelatedtoanypriorpracticeasahearingaiddispenser,orotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No

Iftheanswertoanyoftheabovequestions,numbers11through17,is“Yes,”provideacompleteexplanationofthecircumstancesleadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.

AffidAvit of Good MorAl ChArACter

This affidavit is to be executed before a notary public:

Stateof:__________________________________________________

Countyof:________________________________________________

I, _________________________________________ ,ampersonallyacquaintedwith _____________________________________

andnotrelatedbybloodormarriagetotheapplicant.Ihaveknowntheapplicant_____________ .Iherebyattestthattheapplicantisofgoodmoralcharacterandrepute.

Name:________________________________________________________________________

Address: ______________________________________________________________________

Signature: _____________________________________________________________________

Swornandsubscribedtobeforemethis__________________

dayof ____________________________ ,______________ MonthYear

__________________________________________________ NameofNotaryPublic(pleaseprint)

__________________________________________________ SignatureofNotaryPublic

Affix Seal Here

} ss.

Nameofapplicant

Years/Months

WAiver

Iherebyauthorizeallinstitutions,myreferences,employerspastandpresent,businessandprofessionalassociations,andallprivate,personnel andgovernment agenciesor instrumentalities (local, state, federal and foreign) to release to theHearingAidDispensersExaminingCommittee,anyinformationwhichismaterialtomyapplication.

Ihavecarefullyreadthequestionsinthisapplicationandhaveansweredthemcompletely,withoutreservationsofanykind,anddeclareunderpenaltyofperjurythatmyanswersandallstatementsmadebymehereinaretrueandcorrectandthatIamthepersonreferredtointhisapplication.

ShouldIintentionallyfurnishanyfalseinformationinthisapplication,Iherebyagreethatsuchactsshallconstitutecausefordenial,suspensionorrevocationofmylicensetopracticeasanHearingAidDispenserintheStateofNewJersey.

Ihavereadtheaboveandunderstandthesame.

__________________________________________________ Signatureofapplicant

Swornandsubscribedtobeforemethis__________________

dayof ____________________________ ,______________ MonthYear

__________________________________________________ NameofNotaryPublic(pleaseprint)

Affix Seal Here

__________________________________________________ SignatureofNotaryPublic

New Jersey Office of the Attorney General

Division of Consumer AffairsState 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 CommitteeSponsor’s Affidavit

Please complete and return this affidavit with the completed application.

I hereby affirm that I am currently licensed and registered to practice hearing aid dispensing in New Jersey. I have been activelypracticinginNewJerseycontinuouslysince_____________.PursuanttoN.J.S.A.45:9A-16b,N.J.A.C.13:35-8.3andN.J.A.C. 13:35-8.6, Iherebyagree toassume full responsibility for the supervisionand trainingof_____________________________ uponreceiptofaTrainingPermit, in therequisiteskills,methodsandtechniquessoas toensurecompetencyin thefittingand dispensingofhearingaids.Theapplicantwilltrain FULLTIME PARTTIMEatmybusinesslocation.Iwillassumefull responsibilityforandguaranteethetrainee’sactivitiesintheselling,testing,fittinganddispensingofthehearingaids.

PursuanttoN.J.S.A.45:9A-16aandN.J.A.C.13:35-8.5and8.6,Iwillassumefullresponsibilityforandguaranteethetemporary licenseof_____________________________andhis/hersupervision,trainingandactivitiesintheselling,fittinganddispensing ofhearingaids.

_______________________________________________________ ___________________________________BusinessName Telephonenumber(includeareacode)

________________________________________________________________________________________________________________________________________________________________________________________________________________ StreetAddress City State ZIPCode

Thefirm’sSupervisingLicensee’sname(N.J.A.C.13:35-8.8):

_______________________________________________________ ____________________________________Name Licensenumber

Thesponsormust enclose copiesofhis/heroriginalN.I.H.I.S.certificatesindicatingthecompletionofaminimumof20continuingeducationcoursehoursduringthePREVIOUS BIENNIALREGISTRATION PERIOD.

____________________________________________________ ______________________________________________Sponsor’sSignature Date LicenseNumber

Swornandsubscribedtobeforemethis

dayof__________________________,_____________ Month Year

____________________________________________________________________________________NameofNotaryPublic(pleaseprint)

____________________________________________________________________________________SignatureofNotaryPublic

Affix Seal Here

New Jersey Office of the Attorney General

Division of Consumer AffairsState Board of Medical Examiners

Hearing Aid Dispensers Examining Committee P.O. Box 183

Trenton, New Jersey 08625(609) 826-7100

CertifiCation and authorization form for a Criminal history BaCkground CheCk

Directions: Answer all of the questions on this form.

1. Name _________________________________________________________ ( ________________________) LastFirstMiddle MaidenName

2. Address ___________________________________________________________________________________________ Street or P.O. Box City State ZIP code

3. Date of birth __ __ /__ __ /__ __ Sex: Male Female MonthDayYear

4. Social Security number _________/ _____ / ________

5. Have you completed the fingerprinting process for any Board or Committee of the New Jersey Division of Consumer Affairs since November 2003? Yes No

If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background check process. No payment is necessary as of now.

If “Yes,” please provide the following information and follow the instructions outlined below:

_______________________________________________ _______________________________________________ Board or committee requiring the fingerprinting Month and year you were fingerprinted

If you were fingerprinted after November 2003 as part of the criminal history background process for licensure or certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check conducted for the Department of Education, another state agency or another state does not apply) you will not be required to be fingerprinted a second time. However, the Division must perform a criminal history background check each time you apply for licensure or certification. The fee for this service is $18.75. Payment should be made in the form of a check or money order payable to the State of New Jersey and should accompany your application packet.

6. Have you ever been arrested and/or convicted of a crime or offense? (Minor traffic offenses such as a parking or speeding violations need not be listed.) Yes No

Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted with this form. Failure to follow these instructions may result in the denial of an initial application. Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county where those orders, disposing of the conviction, were issued and filed. Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee within five (5) business days if you are convicted of any crimes or offenses after this form has been completed.

Continuation on the reverse side ➨

Mr. Mrs. Ms.

BoardorCommittee________________________

Official Use Only

Resubmit________________________

Official Use OnlyDualLicense

LicenseType1________________________

Applicant’sNumber________________________

LicenseType2________________________

Applicant’sNumber________________________

CertifiCation

I, ______________________________________________, in making this application to the Board or Committee forcertification or licensure, certify that I am the applicant and that all of the information provided in connectionwith thisapplicationistruetothebestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemedsufficienttodenycertificationorlicensureortowithholdrenewaloforsuspendorrevokeacertificateorlicenseissuedbytheBoardorCommittee.

I voluntarily consent to a thorough investigation ofmy present and past employment and other activities for the purposeof verifyingmyqualifications for certification or licensure. I further authorize all institutions, employers, agencies and allgovernmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or recordsrequestedbytheBoardorCommittee.

Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymearewillfullyfalse,Iamsubjecttopunishment.

__________________________________________________________ _________________________________ SignatureofapplicantDate

Rev. 1/2/19