Instructions/application/personal Certification-State Of New Jersey Form Page 3
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4Individual completing form check below:
Officer/Partner/Member/Owner______
PERSONAL CERTIFICATION
Director
________
Stockholder ________
(This blank form may be reproduced)
Employee ______
___________
1.
Name ___________________________________________________________________________
_______
___________
2.
Residence Address ____________________________________________________
____________________
___________
3.
Business Address __________________________________________________________
_______________
___________
4.
Date of Birth _________________________Place of Birth __________________________
______________
___________
5.
Telephone No. (_____)_______________
____________Social Security Number______________________
NOTE: Disclosure of Social Security Numbers is mandatory for child support enforcement purpose. The
authority to compel disclosure of Social Security Numbers is established by P.L. 1996, c.7 and N.J.A.C. 3:1-20.
6.
Employment History for Five Year Period Preceding the Date of This Application
Date
(Include present employment as well as preceding five years)
From
To
Name, Location & Type of Business
Position & Nature of Duties
Attach additional sheet if more space is needed to complete employment history
7.
Are you over 18 years of age? Yes _____ No _____.
Are you a citizen of the United States? Yes_______ No_______. If no,
in what country do you hold citizenship? ____________________________.
8.
Have you ever been arrested, indicted, convicted or pleaded “nolo contendere” to any offense, crime, or misdemeanor (other than
a motor vehicle violation) in this state, any other state, or any federal jurisdiction? Yes_______ No_______ If “yes”, complete
found on
ARREST FORM
9.
Have any fines or penalties been levied against you by any state, municipality or federal agency? Yes_______ No_______
10.
Have you been involved in any material litigation during the five-year period prior to application? Yes_______ No______
11.
Are you now under investigation in this state, any other state, or federal jurisdiction? Yes _____ No _____
12.
Have you ever held any license issued by the Department of Banking and Insurance? Yes _____ No _____
13.
Have you ever had a license or right to engage in any business which is the subject of this application or any other business or
profession denied, revoked, suspended, otherwise restrained by any agency of this state, any other state, or by the federal
government? Yes_______ No_______
14.
Have you ever filed a petition in bankruptcy or reorganization or been affiliated with any entity that has filed a petition in
bankruptcy or reorganization? Yes_______ No_______.
15.
Are you the subject of an arrest warrant for failing to comply with court ordered child support obligations? Yes_____ No____
Are you in arrears on such obligations for a period of six months or more? Yes_____ No_____.
For “No” response to either question contained in Question 7, refer to the website for an
explanation of supporting documentation
requirements.
For “Yes” responses to Questions 8 thru 15, refer to the website for an
explanation of supporting documentation
requirements. Failure
to provide the specific information requested will cause the application to be returned to you.
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