Get NJ PA-94-1 2019-2024

O. Box 183 Trenton New Jersey 08625 609 826-7100 BMEPA dca.lps. state. nj. us Use this checklist as a guide to assure your application is complete. IV. Fees Please forward a check or money order in the amount of 125. 00 with your application. If approved for licensure you will be notified to forward the licensure fee of 220. 00. This fee is not refundable. Dear Applicant Enclosed please find a New Jersey application for licensure. However the Division must perform a criminal history background check each time you apply for licensure or certification. The fee for this service is 17. Have worked in a medical capacity within the past five 5 year period that immediately precedes the submission of your application for licensure in New Jersey. I further swear or affirm that I have read N.J.S.A. 45 9-27. 10 et seq. together with the Rules and Regulations of the Physician Assistant Advisory Committee N.J.A. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false I am subject to punishment. 54 50-24 et seq. of the New Jersey taxation law N.J.S.A. 2A 17-56. 44e of the New Jersey Child Support Enforcement Law Section 1128E b 2 A of the Social Security Act and 45 C. Applicant s name I. Application A. Answer each question completely. B. Be sure to have the application notarized* C. Attach one 1 passport photograph 2 x 2 to the application* D. Provide a valid daytime telephone number include area code. E* Attach additional documents if applicable. For example to explain gaps in curriculum vitae history a statement of medical activity or other. List here F* Provide the original or a notarized copy of your birth certificate a notarized copy of your passport or citizenship documents. G* Provide name-change documentation a notarized copy of the marriage license/court orders if applicable. II. Verification forms a* Military Service Profile PA-94-ll-A Yes N/A b. P. A. License s /Registration PA-94-ll-B c* N*C. C. P. A. Verfication PA-94-ll-C d. Certification of Good Standing PA-94-ll-D with one 1 passport photograph 2 x 2 PA-94-ll-F attached. f* Employer s Verification of Hospital/Medical Employment Privileges or Appointment PA-94-ll-H Checklist III. Transcripts Verification of Education IV. Curriculum Vitae V. Personal check or money order payable to the Physician Assistant Advisory Committee in the amount of 125. In order for your application to be processed you must adhere to the following guidelines in conjunction with the checklist provided* Failure to answer each question completely will result in your application being returned to you for a response. Very Important Please read the application form in its entirety before completing. Note Under the Medical Conditions section of the application there are instances when not applicable may apply. It will be your responsibility to contact the N*C. C. P. A. and have them send us your verification or certification* The issuing authority state or employer must return the applicable form directly to the Physician Assistant Advisory Committee at the address listed on the form* Forms submitted to the Physician Assistant Advisory Committee by an applicant will not be accepted* Forward a copy of this form to every branch of the U*S* military service i n which you have served* The military branch es should be advised that profiles that are incomplete will not be accepted* licensed/certified as a health care professional other than a physician assistant.