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Get NJ Application For Licensure As A Clinical Alcohol And Drug Counselor Or Certification 2019-2024

54 50-24 et seq. of the New Jersey taxation law N.J.S.A. 2A 17-56. 44e of the New Jersey Child Enforcement Law Section 1128E b 2 A of the Social Security Act and 45 C. D. /Psy. D. - Psychologist M. D. /D. O. L.C. S.W. A. P. N. L.P. C. L.M. F.T. Other Specify Addiction Professionals Certification Board of New Jersey. Failure to do so may result in denial of licensure/certification/reinstatement/reactivation. Individual Taxpayer Identification Number Pursuant to N.J.S.A. 44d an answer of Yes to any of the questions a through d may result in denial of licensure or certification. Furthermore any false certification of the above may subject you to a penalty including but not limited to immediate revocation or suspension of licensure or certification. Applicant s name please print Applicant s signature 7. A. - 5 ALANON - 5 N.A. - 5 A. A. location OTHER - 15 Name of other self-help groups Can include additional A. Attach two full-face passportstyle photographs 2 x 2 of your head and shoulders taken within the past six months. I have not completed the required written and oral examination for certification/licensure as an alcohol and drug counselor. Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act OPRA. O. Box 45040 Newark New Jersey 07101 973 504-6582 Written Examination Oral Examination Written and Oral Examinations Date exam passed Certified Alcohol and Drug Counselor C. 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 code. Please print clearly. You must answer all of the questions on this application* Personal Information 1. Name Date of birth Month Day Year Place of birth City Mr. State Country Mrs. Last name First name Middle initial Maiden name Ms. 2. Address Home Street or P. O. Box ZIP code Telephone number include area code E-mail address Business Name of company Street Mailing 3. Social Security Number If you were issued a Social Security Number or an Individual Taxpayer Identification Number you must provide it to the Board or Committee. F*R* 60. 7 60. 8 and 60. 9 the Board or Committee is required to obtain this information* Pursuant to these authorities the Board or Committee is also obligated to provide this information to For healthcare-related boards the following a b and c entries apply. For boards not related to healthcare only the a and b entries apply. 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.

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