application for certification as a certified social worker ... · education - pursuant to n.j.a.c....
TRANSCRIPT
For Office Use Only
New Jersey Office of the Attorney GeneralDivision of Consumer Affairs
State Board of Social Work Examiners124 Halsey Street, 6th Floor, P.O. Box 45033
Newark, New Jersey 07101(973) 504-6495
Website: http://www.njconsumeraffairs.gov/social/
Application for Certification as a Certified Social WorkerPursuant to N.J.S.A. 45:15BB-6 / N.J.A.C. 13:44G-4.3
Date:
Anonrefundableapplicationfilingfeeof$75,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
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
Attachaclear,full-facepassport-stylephotograph(2˝x2˝)ofyourheadandshoulders,takenwithinthepastsixmonths.A photo is requiredwith eachapplication.
Donotuseapapercliptoattachthephoto.
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
Pleasecertify,underpenaltyofperjury,thefollowing:
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 No
Ifyouanswered“Yes,”areyoucurrentlyparticipatinginasupervisedrehabilitationprogramorprofessionalassistanceprogram thatmonitorsyouinordertoassurethatyouarenotengagingintheillegaluseofcontrolleddangeroussubstances?
Yes No
_____________________________________________________ ___________________________________ Applicant’ssignature Date
7. Haveyoueverbeenconvictedofacriminaloffense?(Minortrafficoffensessuchasparkingorspeedingviolationsneednotbe listed;however,motorvehicleoffensessuchasdrivingwhileimpairedorintoxicatedmustbedisclosed.) Yes No If“Yes,”provideacertifiedorofficialcopyofthejudgmentofconviction,acertifiedorofficialcopyofthereleasefromparole orprobationand/oranofficialdocumenttoverifycompliancewithanytermsimposedrelatedtotheconviction(s).Pleaseprovide acompleteexplanation.(Attachadditionalsheetsofpapertothisapplication.)
8. Doyoucurrentlyhold,orhaveyoueverheld,aprofessionallicenseorcertificateofanykindinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
If“Yes,”foreachlicenseorcertificateheld,providethedate(s)heldandthenumber(s).Ifthelicenseorcertificatewasissuedunder adifferentname,pleaseprovidethatname.____________________________________________________________________ LastnameFirstname Middleinitial
_____________________ _______________________ ____________________________ ____________________ Typeoflicenseorcertificate Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________ Typeoflicenseorcertificate Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________ Typeoflicenseorcertificate Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________ Typeoflicenseorcertificate Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
_____________________ _______________________ ____________________________ ____________________ Typeoflicenseorcertificate Number Stateorjurisdictionthatissuedthelicenseorcertificate Dateissued/expired
Note: Ifyouarelicensedorcertifiedasasocialworkerinanyotherstate,theDistrictofColumbiaorinanyotherjurisdiction,itisyour responsibilitytocontactthelicensingboardinthatjurisdictiontorequestthatverificationofyourlicensureorcertificationbesent directlytotheNewJerseyStateBoardofSocialWorkExaminers.
9. HaveyoueverbeendisciplinedordeniedasocialworklicenseorcertificateoranyotherprofessionallicenseorcertificateinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
10. Haveyoueverhadaprofessionallicenseorcertificateofanytypesuspended,revokedorsurrenderedinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
11. Hasanyaction(includingtheassessmentoffinesorotherpenalties)everbeentakenagainstyourprofessionalpracticebyanyagencyorcertificationboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
12. HaveyoueverbeennamedasadefendantinanylitigationrelatedtothepracticeofsocialworkorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
13. AreyouawareofanyinvestigationpendingagainstaprofessionallicenseorcertificateissuedtoyoubyaprofessionalboardinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
14. ArethereanycriminalchargesnowpendingagainstyouinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
15. Haveyoueverbeensanctionedbyorisanyactionpendingbeforeanyemployer,association,society,orotherprofessionalgrouprelatedtothepracticeofsocialworkorotherprofessionalpracticeinNewJersey,anyotherstate,theDistrictofColumbiaorinanyotherjurisdiction? Yes No
Iftheanswertoanyoftheabovequestions,numbers9through15,is“Yes,”provideacompleteexplanationofthecircumstancesleadingtotheaction,andanysupportingdocumentation,onseparatesheetsofpaper.
Education-PursuanttoN.J.A.C.13:44G-4.3,a baccalaureate degree in social work (B.S.W.)fromacollegeoruniversityofferinganeducationalprogramaccreditedbytheCouncilonSocialWorkEducationisrequiredtoobtaincertificationasacertifiedsocialworker.
1. Whatisthenameandaddressofthecollegesoruniversitiesyouhaveattended?
Nameandcompleteaddressofcollegeoruniversity
Datesattendedmonth/yeartomonth/yearDegreeDategranted
Nameandcompleteaddressofcollegeoruniversity
Datesattendedmonth/yeartomonth/yearDegreeDategranted
Nameandcompleteaddressofcollegeoruniversity
Datesattendedmonth/yeartomonth/yearDegreeDategranted
2. An official transcript sent by the educational institution granting the qualifyingB.S.W. degreemust become a part of thisapplication.
Transcriptrequestedfrom: Transcriptenclosed __________________________________________________________________ Nameofcollegeoruniversity
NoactionwillbetakenonyourapplicationuntiltheB.S.W.transcripthasbeenreceived.
For Board UseDate Received
Current Employment
PleasehaveyourdirectsupervisorprovidedetailedinformationaboutyourcurrentNewJerseysocialworkemployment.(Ifyouarecurrentlyunemployed, notemployedinNewJerseyor, employedinasettingwhichisclearlyunrelatedtothefieldofsocial
work,pleasedonotcompletethispage.)
Nameofinstitution,company,agencyorprivatepractice Streetaddress
City State ZIPcode Telephonenumber(includeareacode)andextension
Nameofsupervisor Supervisor’stitle Supervisor’slicenseorcertificatenumber
Datethatyouwerehired:
Month/Day/Year Jobtitle Profitstatusofinstitution,company,agencyorprivatepractice
Adetaileddescriptionoftheapplicant’sjobfunctionsandresponsibilities(PleaserefertoN.J.A.C.13:44G-1.2forthedefinitionsof“clinicalsocialworkservices”and“socialworkservices.”):
_______________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
___________________________________ ___________________________________ ________________________ Supervisor’ssignature Credentials Date
AffidAvit
This affidavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the State Board of Social Work Examiners for licensure or certification under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the State Board of Social Work Examiners, swear (or affirm) that I am the applicant and that all information provided in connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufficient to deny certification or licensure or to withhold renewal of or suspend or revoke a license or certificate issued by the Board.
I further swear (or affirm) that I have read N.J.S.A. 45:15BB-1 et seq., together with the Rules and Regulations of the State Board of Social Work Examiners, N.J.A.C. 13:44G-1.1 et seq., and fully understand that in receiving licensure or certifica-tion from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose of verifying my qualifications for licensure or certification. I further authorize all institutions, employers, agen-cies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or records requested by the Board.
_____________________________________________ Applicant’s signature
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
_____________________________________________ Name of Notary Public (please print)
Affix Seal Here
Month Year
_____________________________________________ Signature of Notary Public
} ss.
New Jersey Office of the Attorney General
Division of Consumer AffairsState Board of Social Work Examiners
P.O. Box 45033Newark, New Jersey 07101
(973) 504-6495
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