New Jersey Office of the Attorney General Division of ...

1 New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing124 Halsey Street, 6th Floor, Box 45010 Newark, New Jersey 07101(973) FOR HOMEMAKER-HOME HEALTH AIDE CERTIFICATIONP lease read the following information carefully before completing an application for homemaker-home health aide (HHA) you previously held HHA certification in New Jersey , DO NOT complete this application. You must contact the Certified Homemaker-Home Health Aide Renewal Department in order to complete the Application for Reinstatement. 1. Complete an application for HHA Initial Certification. Answer ALL of the questions. 2. Sign the application in the presence of a notary public. 3. Attach a clear, full-face original passport photograph (2 x 2 ) of your head and shoulders taken within the past six months.

2 Sign your name on the front of the picture. (Photocopies and selfies are not acceptable.) 4. If you are a citizen, please submit a copy of your birth certificate or passport. 5. If you are a naturalized citizen, please submit a copy of your passport or certificate of naturalization. 6. If you are a legal alien or other immigration status, please submit your USCIS immigration documents. (Submit a copy of both the front and the back of your card.) 7. Submit proof of legal name change ( , marriage license, divorce decree, court order, if applicable) if your name differs from that on your birth certificate. 8. Complete the Certification and Authorization form for a Criminal History Background Check. 9. Submit criminal history documents (if applicable).

3 10. Submit a check or money order for your application and certification fees in the amount of either $ or $ (please consult the fee schedule on the Board s website at: ) made payable to the New Jersey Board of Nursing. The application fee of $ is nonrefundable. 11. Upon receipt and review of: 1) a Letter of Completion sent directly from your HHA training program; and 2) a signed promise of employment on official company letterhead from an agency approved to employ HHAs, you may receive your 120-day Temporary Work Permit. 12. You will receive digital fingerprint information via regular mail. Please schedule your appointment as soon as possible. 13. If your criminal background check results reveal no convictions for disqualifying offenses or other crimes, you will be certified.

4 If your criminal background results reveal convictions for disqualifying offenses or other crimes, your application must be reviewed by the Board s disciplinary committee. 14. Please notify the Board of any change of address or change in your contact information. New Jersey Office of the Attorney GeneralDivision of Consumer AffairsNew Jersey Board of Nursing124 Halsey Street, Box 45010 Newark, New Jersey 07101(973) 504-6430 ApplicAtion to Become A certified HomemAker-Home HeAltH Aide (including tHe certificAtion And AutHorizAtion for A criminAl History BAckground cHeck)Directions: Answer all of the questions on both sides of this application and certification. Attach a recent passport-style photograph to the designated spot on the last page of this form.

5 In order to complete the criminal history review process, you must complete a Certification Authorization form and obtain electronic fingerprinting. The necessary forms needed to obtain the electronic fingerprinting, which will initiate the criminal history background check, will be provided by the Board of Nursing. However, it is your responsibility to schedule an appointment for the fingerprinting. This application and certification must be signed and notarized. You must attach a check or money order, made payable to the New Jersey Board of Nursing, to cover the cost of the application and certification. Please be advised that the application fee is nonrefundable. The certification fee is refundable. (Applicants should understand that if the application filing fee is paid with a personal check, and the check is returned by the bank due to insufficient funds, the next step in the licensure process will be delayed until the fee is paid.)

6 The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their consent. However, you are required to provide an address that may be released to the public in our directories or in response to other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of your place of residence, you should provide an address of record other than your place of residence that may be released to the public. One of your addresses must include a street, city, state and ZIP that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).

7 Please print clearly. You must answer all of the questions on this Information Name Mrs. _____( _____) Ms. Last name First name Middle initial Maiden name2. Address Home: _____ Street City State ZIP code County Mailing: _____ Street or Box City State ZIP code County Home telephone number _____ Cellular telephone number _____ (include area code) (include area code)Social Security number _____ E-mail address _____ (See Item number 6 on next page.)3. Have you ever changed your name? Yes No (Please submit proof of legal name change.)4. Date of birth __ __ /__ __ /__ __ Sex: Male Female Place of birth _____ Month Day Year City State or Country If you are a - born citizen, please submit your birth certificate.

8 If you are a foreign-born/naturalized citizen, please submit your passport OR certificate of Height _____ Weight _____Eye color _____ Hair color _____120-Day Period:Begins _____Ends_____Official Use OnlyBoard of Nursing Candidate s Number_____If you have ever held certification as a homemaker-home health aide in New Jersey , you should not fill out this application. You should instead fill out the Application for Reinstatement of a Homemaker-Home Health Aide Certification which may be obtained from the note that your criminal history background check must be complet-ed within the 120-day conditional certification period. If this is not accomplished, your conditional certification will be Social Security Number You must provide your Social Security number to the Board or Committee.

9 Failure to do so will result in denial/nonrenewal of licensure or certification. *Social Security Number: _____-_____- _____ *Pursuant to 54:50-24 et seq. of the New Jersey taxation law, 2 of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 , and , the Board or Committee is required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide your Social Security number to: a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing compliance with State tax law and updating and correcting tax records; b. the Probation Division or any other agency responsible for child support enforcement, upon request; and c.

10 The National Practitioner Data Bank and the Data Bank, when reporting adverse actions relating to health care Citizenship / Immigration Status Federal law limits the issuance or renewal of professional or occupational licenses or certificates to 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 citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the Office of Citizenship and Immigration Services (USCIS). citizen Alien lawfully admitted for permanent residence in 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: Student Loan Are you in default in regard to any student loan obligation(s)?