New Jersey Department of Health

PUBLIC HEALTH LICENSING AND EXAMINATION BOARD

P.O. Box 360

Trenton, New Jersey 08625-0360

APPLICATION FOR HEALTH OFFICER EXAMINATION	DO NOT WRITE IN THIS SPACE
Before filling out application familiarize yourself with the qualifications for admission to this examination in N.J.A.C. 8:7. Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).

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

CHECK THE EXAMINATION DATE FOR WHICH YOU ARE APPLYING:

May November

1.	Name:
(Last Name) (First Name) (Middle Initial)
(Maiden Name)
2.	Address:
Home:
(Street Address or PO Box)
(County)
(City)
(State)
(ZIP + Four)
(Telephone Number (Including Area Code)
(Email Address)
Business:
(Street Address or PO Box)
(County)
(City)
(State)
(ZIP + Four)
Mailing:
(Street Address or PO Box)
(County)
(City)
(State)
(ZIP + Four)
3.	Date of Birth:
Place of Birth:
(Month/Day/Year)
(City) (State)
4.	*Social Security Number:
You must disclose your Social Security number for the reasons stated below. Failure to do so may result in a denial of licensure.

*Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey Child Support Enforcement Law and N.J.S.A. 54:50-25 of the New Jersey taxation law, the Department is required to obtain your Social Security number. Pursuant to these authorities, the Department 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; and (b) the Probation Division or any other agency responsible for child support enforcement, upon request. If you do not have a Social Security number, the Board must ascertain the reason that you do not have one.

5.	Citizenship/Immigration Status:
Federal law limits the issuance or renewal of professional or occupational licenses or certificates to U.S. 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 U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the office of the U.S. Citizenship and Immigration Service (USCIS).
U.S. Citizen
Alien lawfully admitted for permanent residence in the U.S.
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 1-800-375-5283.
6.	Student Loan:
Are you in default in regard to any student loan obligation(s)?	Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued your student loan, for the eventual payment of the loan. You will not be able to obtain a license unless you provide the required documents concerning the plan for payment of your student loan.
7.	Child Support:
Please certify, under penalty of perjury, the following:
a.	Do you currently have a child-support obligation?	Yes No
(1)	If “yes,” are you in arrears in payment of said obligation?	Yes No
(2)	If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?	Yes No
b.	Have you failed to provide any court-ordered health insurance coverage during the past six months?	Yes No
c.	Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding?	Yes No
d.	Are you the subject of a child-support-related arrest warrant?	Yes No
In accordance with N.J.S.A. 2A:17—56.44d, an answer of “Yes” to any of the questions a(1) though d will result in a denial of licensure. Furthermore, any false certification of the above may subject you to a penalty, including, but not limited to, immediate revocation or suspension of licensure.
(Name of Applicant) (Print)
(Signature of Applicant)
(Date)
8.	Have you ever changed your name?	Yes No
If “Yes,” please submit a copy of the marriage certificate, divorce decree or court order with this application.
9.	Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention (PTI); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle violations such as driving while impaired or intoxicated must be).	Yes No
10.	Have you ever been convicted of any crime or offense under any circumstances? (This includes, but is not limited to, a plea of guilty, non vult, nolo contendere, no contest, or a finding of guilt by a judge or jury.)	Yes No
11.	Do you currently hold, or have you ever held, a professional license or certificate of any kind in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
If “Yes,” for each professional license or certificate held, provide the date(s) held and the number(s). If the license or certificate was issued under a different name, please provide that name.
(Last Name) (First Name) (Middle Initial)
(Type of License or Certificate)
(Number)
(Issued By: State or Jurisdiction)
(Date Issued/Expired)
(Type of License or Certificate)
(Number)
(Issued By: State or Jurisdiction)
(Date Issued/Expired)
(Type of License or Certificate)
(Number)
(Issued By: State or Jurisdiction)
(Date Issued/Expired)
(Type of License or Certificate)
(Number)
(Issued By: State or Jurisdiction)
(Date Issued/Expired)
12.	Have you ever applied for a Health Officer licensing examination and been determined ineligible by the Public Health Licensing and Examination Board?	Yes No
13.	Have you ever applied for a Health Officer licensing examination and been found eligible by the Public Health Licensing and Examination Board but failed the examination?	Yes No
14.	Have you ever been disciplined or denied a Health Officer license or any other professional license or certificate in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
15.	Have you ever had a professional license or certificate suspended, revoked, or surrendered in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
16.	Are you aware of any investigation pending against a professional license or certificate issued to you by a professional board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
17.	Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
18.	Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group related to any professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?	Yes No
If the answer to any of the above questions, numbers 9 through 18, is “Yes,” provide a complete explanation of the circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
EDUCATION RECORD
Beginning with the most recent, list all undergraduate and graduate institutions which you attended.

Attach ORIGINAL official transcript(s) of your College, University, and Post-graduate work. Copies of student-issued transcripts will not be accepted.
Name and Location of Schools	Dates Attended	Major	Minor	Credit Hours	Degree and Date
From	To
Semester	Quarter
EMPLOYMENT RECORD
Beginning with your present position and working back, list and describe, as indicated, every position in which you have been employed, including military service. In describing your work be as specific as possible with regard to your duties, responsibilities, and number of persons you supervised.

(IF ADDITIONAL SPACE IS NEEDED, ATTACH SUPPLEMENTAL SHEETS)
Name and Address of Employer

Description of Your Work

Title of Present or Last Position

Dates of Employment (Month/Year)

From: ______ To: ______	Total Time Employed

______ Years ______ Months
Full Time

Part Time	If Part Time, Give Number of

Hours Worked per Week:
Name and Address of Employer

Description of Your Work

Title of Present or Last Position

Dates of Employment (Month/Year)

From: ______ To: ______	Total Time Employed

______ Years ______ Months
Full Time

Part Time	If Part Time, Give Number of

Hours Worked per Week:
EMPLOYMENT RECORD (Continued)
Name and Address of Employer

Description of Your Work

Title of Present or Last Position

Dates of Employment (Month/Year)

From: ______ To: ______	Total Time Employed

______ Years ______ Months
Full Time

Part Time	If Part Time, Give Number of

Hours Worked per Week:
Name and Address of Employer

Description of Your Work

Title of Present or Last Position

Dates of Employment (Month/Year)

From: ______ To: ______	Total Time Employed

______ Years ______ Months
Full Time

Part Time	If Part Time, Give Number of

Hours Worked per Week:
Name and Address of Employer

Description of Your Work

Title of Present or Last Position

Dates of Employment (Month/Year)

From: ______ To: ______	Total Time Employed

______ Years ______ Months
Full Time

Part Time	If Part Time, Give Number of

Hours Worked per Week:
ADDITIONAL EXPERIENCE AND TRAINING
Describe any other experience or training in addition to the foregoing which you believe will support your qualifications for the Health Officer examination. Do not repeat experience or training which you have already listed in another section of this application.

(IF ADDITIONAL SPACE IS NEEDED, ATTACH SUPPLEMENTAL SHEETS)
TRAINING REQUIRED BY BOARD
If you have failed the Health Officer examination two times, list below the area(s) in which you were deficient and the formal training and/or supervised experience that was required by the Board in order for you to be eligible to make the reapplication. If you were required to take formal classroom training, you must submit proof of attendance in the form of an official transcript for a college course or a certificate of attendance from a short course. If you received additional supervised experience, you must submit a letter from your supervisor detailing the nature of the experience, the duties, and any staff supervised.
A.	Deficient Area(s):
B.	Formal Training / Course: Yes No
Name of Course(s):
Where Obtained:
Dates Attended:	From:	To:
C.	Supervised Experience: Yes No
Name of Supervisor:
Location:
From:	To:
REFERENCES
Please give the names of three persons who are familiar with your work that may be contacted by the Board if inquiries are necessary:
1.
(Name)
(Affiliation)
(Address)
(Telephone Number (Including Area Code)
(Email Address)
2.
(Name)
(Affiliation)
(Address)
(Telephone Number (Including Area Code)
(Email Address)
3.
(Name)
(Affiliation)
(Address)
(Telephone Number (Including Area Code)
(Email Address)
HEALTH OFFICER APPLICANT: SUPPLEMENTAL DATA
PLEASE NOTE: All applications must be accompanied by (1) an official transcript issued by the Registrar of a college or university and delivered under seal and (2) a copy of the college or university catalogue description of the courses required pursuant to the provisions set forth at Licensure of Persons for Public Health Professions, N.J.A.C. 8:7. Applications filed without transcript and/or catalogue description will be delayed until they are received. Course with grades less than 2.0 (“C”) shall not be considered.
EDUCATION
A.	Degree(s) Earned and Date(s):
B.	Name of Institution Granting Degree:
C.	Name of Major/Health-Related Field:
The above Degree must include or be supplemented by at least three graduate or upper-level under-graduate credit hours in the following subject areas	List the course name and course number which satisfies the listed requirement. Include a copy of the college catalogue description for the particular course(s).
1.	Planning	Yes	No
2.	Administration	Yes	No
3.	Environmental Science	Yes	No
4.	Social Science	Yes	No
5.	Epidemiology	Yes	No
6.	Biostatistics	Yes	No
EXPERIENCE
You must have a minimum of two (2) years of full-time employment in a position which provides administrative experience in at least three of the five existing recognized public health activities listed below. Check the areas in which you are claiming you have the requisite experience.

Administration and Support Services	Maternal and Child Health

Environmental Health	Chronic Illness

Communicable Diseases

NOTE: Official documentation from your supervisor verifying in detail your employment experience must be submitted with your application. Failure to do so will delay review of your application.
DECLARATION
I certify, under the penalty of perjury under the laws of the State of New Jersey, that this application contains no willful misrepresentations of falsifications and that the information given by me in connection with this application for licensure as a Health Officer is true, correct and complete. I am aware that if an investigation discloses any misrepresentation to any answer to questions on this form, the application will be rejected. I further understand that any false statement knowingly made by me is grounds for denial of licensure or revocation of a license issued in reliance upon false information.
(Date)
(Signature of Applicant)
(Maiden Name, if applicable)
IMPORTANT:

Admission to the Health Officer examination is dependent upon the information furnished in this application. The application must be accompanied by documentary evidence which supports your training, education, and experience. All letters verifying your experience must list in detail all the duties, responsibilities, number of staff supervised if any, and length of time you served in a particular field. An official transcript under seal must be submitted from your college(s) or university(ies). Student copies will not be accepted. An application is not deemed complete and ready for review by the Board unless and until all required documentary evidence is received prior to the published application deadline. The deadline shall be enforced according to the postmark on the packet and on any supplemental material. Photostatic copies of certificates, awards, or other similar documents are appropriate documentation in support of your training qualifications.

It is the responsibility of the applicant to arrange for submission of all required documentation for timely completion of the application. The Board does NOT notify applicants of incomplete documentation.

Licensure requirements are subject to change as a result of new legislation, rules, or due to new policies and procedures that may be adopted by the Board. Applicants must meet current requirements.
BEFORE SUBMITTING THIS APPLICATION:

(	Have you answered all questions completely and carefully?

(	Have you signed the application?

(	Have you included or arranged for official transcripts to be submitted?

(	Have you included all necessary documentary evidence in support of your training?

(	Have you included a non-refundable $50.00 application fee in the form of a check or money order made payable to “Treasurer, State of New Jersey”?

“Administrative experience” means work performed under minimal supervision requiring initiative, decision making, and independent judgment.

APPLICATION FOR HEALTH OFFICER EXAMINATION

(Continued)

LH-8

JUL 12	Page 8 of 8 Pages.

JUL 12	Page 1 of 8 Pages.

LH-8 , Application for Health Officer Examination

LH-8, public health licensing and examination board, application, health officer, examination

ewhite

2011-02-09

NJDHSS