New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
124 Halsey Street, 6th Floor, P.O. Box 45038
Newark, New Jersey 07101
(973) 504-6331
Training Permit Application Checklist
Please complete and return this checklist with your application. Indicate a (√) mark if the item is being
submitted with the application or if the request for information has been complied with. Indicate “N/A”
if not applicable in your situation. Documentation you have asked others to send directly to the
Committee may be indicated by a brief note: i.e. “Will be sent directly from the State of New York.”
Completed notarized application
Three (3) passport-size (approximately 2” x 2”) professional quality photographs (no home-made Polaroids)
taken within sixty (60) days of submitting the application. Sign the reverse side and indicate the date they
were taken.
FEES: CHECKS OR MONEY ORDERS ONLY.
Make checks or money orders payable to the State of New Jersey. Submit with each application a
nonrefundable $50.00 application fee. Additionally, submit a separate check in the amount of $50.00 for a
training permit or temporary license.
Certification and Authorization Form for a Criminal History Background Check. Please submit the completed
form with your application.
SPONSOR: Original N.I.H.I.S. continuing education certificated for 20 hours completed during the previous
biennial registration period. This needs to be done only if you are applying for a temporary license or a
training permit.
Completed Sponsor’s Affidavit form.
Do not use staples to attach the
photographs.
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Attach three clear, full-face passport-style photographs (2˝x 2˝) of
your head and shoulders, taken
within the past six months.
Three photographs are required
with each application.
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
124 Halsey Street, 6th Floor, P.O. Box 45038
Newark, New Jersey 07101
(973) 504-6331
Application for Training Permit
Date:_ ______________________________
_
Please enclose a nonrefundable application filing fee of $50.00 and a training permit fee of $50.00 (total fee $100.00) in
the form of a check or money order made out to the State of New Jersey. (Applicants should understand that if the fees are paid
with a personal check, and the check is returned by the bank due to insufficient funds, the next step in the licensure
or certification process will be delayed until the fees are paid.) You also will be required to pay a certification fee at a later date.
The Committee maintains, as part of its responsibilities, a record of your home address, business address and mailing address. You
may choose which of these addresses will be considered as your “address of record.” If you do not indicate (by putting a check in the
appropriate box) which address should be used as your address of record, your mailing address will be considered to be your address of
record. A post office box may be used as your address of record, but only if you provide another address which includes a street, city,
state and ZIP code.
Information that you provide on this application (including your address of record) 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.
Personal Information
Date of birth: _ ________________________
_
Month Day Year
Place of birth: _________________________
City State
1. Name
Mr.
Mrs. _________________________________________________________________ (________________________)
Last name
First name
Middle initial
Maiden name
Ms.
2. Address
Home:_______________________________________________________________________________________________
Street or P.O. Box
State
______________________________________
ZIP code
County
___________________________________
Telephone number (include area code)
E-mail address
Business:_____________________________________________________________________________________________
City
Name of company
Telephone number (include area code)
_____________________________________________________________________________________________
Street
City
State
ZIP code
County
Mailing:_ ____________________________________________________________________________________________
Street or P.O. Box
City
State
ZIP code
County
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certification.
*Social Security Number: _ __________ -____________ -____________
*Pursuant to N.J.S.A. 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.F.R. 60.7,60.8 and 60.9, 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. the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care
professionals.
4. 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 U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in 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.
5. Student Loan
Yes
No
Are you in default in regard to any student loan obligation(s)?
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 repayment of the loan. You will not be able to obtain a license or certificate unless you provide the
required documents concerning the plan for repayment of your student loan.
6. 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) through d will result in a 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
_________________________
Date
7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the definitions carefully. Your
responses will be treated confidentially and retained separately. Please be aware that you have the right to elect not to answer
those portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you
have reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may
assert the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good
faith. If you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the
application. Your application for licensure or certification will be processed if you claim the Fifth Amendment privilege against selfincrimination. You should be aware, however, that you may later be directed by the Attorney General to answer a question that you
have refused to answer on the basis of the Fifth Amendment, provided that the Attorney General first grants you immunity afforded
by statutory law. (N.J.S.A. 45:1-20.)
For the purposes of these questions, the following phrases or words have the following meanings:
“Ability to practice as a hearing aid dispenser trainee” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of a hearing aid dispenser trainee, and to learn and keep abreast of
professional developments; and
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without the
use of aids or devices, such as voice amplifiers; and
c. The physical capability to perform the duties of a hearing aid dispenser trainee, with or without the use of aids or devices, such as
corrective lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
diabetes, mental retardation, emotional or mental illness, specific learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
prescription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather,
it means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the
previous two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroin or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or
not taken in accordance with the directions of a licensed health care practitioner.
a. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety?
Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No
Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice,
the setting or manner in which you have chosen to practice?
Yes No
Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety?
Yes No
Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is defined as “within
the last two years.”)
Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances?
Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Committee will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to
determine whether an unrestricted license or certificate should be issued, whether conditions should be imposed or whether you
are not eligible for licensure or certification.
_ ____________________________________________________
Signature of applicant
___________________________________
Date
8. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certificate, divorce decree or court order.
9.
Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); 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
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
11. Do you currently hold, or have you ever held, a professional license, certificate or permit of any kind in New Jersey, any other state,
the District of Columbia or in any other jurisdiction?
Yes No
If “Yes,” for each license, certificate or permit 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, certificate or permit
Type of license, certificate or permit
Type of license, certificate or permit
Type of license, certificate or permit
Type of license, certificate or permit
Number
Number
Number
Number
Number
State or jurisdiction that issued the license, certificate or permit
State or jurisdiction that issued the license, certificate or permit
State or jurisdiction that issued the license, certificate or permit
State or jurisdiction that issued the license, certificate or permit
State or jurisdiction that issued the license, certificate or permit
Date issued/expired
Date issued/expired
Date issued/expired
Date issued/expired
Date issued/expired
12. Have you ever been disciplined or denied a professional license, certificate or permit of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction?
Yes No
13. Have you ever had a professional license, certificate or permit of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction?
Yes No
14. Has any action (including the assessment of fines or other penalties) ever been taken against your professional practice by any agency
or certification board in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
15. Have you ever been named as a defendant in any litigation related to any prior practice as a hearing aid dispenser trainee, or other
professional practice 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, certificate or permit 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 prior practice as a hearing aid dispenser trainee, or other 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 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
19. Did you earn a master’s degree in audiology after January 1, 1993?
Yes No
If “Yes,” please arrange for the school at which you completed a master’s degree in audiology to forward a transcript directly to the
Hearing Aid Dispensers Examining Committee.
Experience
1. Please document your work experience below. Begin with your current or most recent experience in the hearing aid field and then
work back in time, chronologically.
(a) Employer:____________________________________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
_ ___________________________________________________________________________________________________
Month
Year
Month
Year
(b) Employer:____________________________________________________________________________________________
Immediate supervisor’s name and title:_____________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
Month
Year
Month
Year
(c) Employer:____________________________________________________________________________________________
Immediate supervisor’s name and title:_____________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
Month
Year
Month
Year
Immediate supervisor’s name and title:_____________________________________________________________________
(d) Employer:____________________________________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
_ ___________________________________________________________________________________________________
Month
Year
Month
Year
(e) Employer:____________________________________________________________________________________________
Immediate supervisor’s name and title:_____________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
Month
Year
Month
Year
(f) Employer:____________________________________________________________________________________________
Address:_____________________________________________________________________________________________
Telephone number:___________________________________
Immediate supervisor’s name and title:_____________________________________________________________________
Street address
City
State ZIP code
(include area code)
Title of your position:___________________________________________________ Hours per week:___________________
Your major responsibilities (use additional sheets of paper if necessary):_ _________________________________________
_
_ ___________________________________________________________________________________________________
_ ___________________________________________________________________________________________________
From_____________________________________________ to_ ________________________________________________
Month
Year
Month
Year
Immediate supervisor’s name and title:_____________________________________________________________________
Affidavit of Good Moral Character
This affidavit is to be executed before a notary public:
State of:___________________________________________________
County of:_________________________________________________
I,_ _________________________________________ , am personally acquainted with_ _____________________________________
Name of applicant
and not related by blood or marriage to the applicant. I have known the applicant______________ . I hereby attest that the applicant is
of good moral character and repute.
Years/Months
Name:_________________________________________________________________________
Address:_ ______________________________________________________________________
Signature:_ _____________________________________________________________________
Sworn and subscribed to before me this___________________
day of_ ____________________________ , _______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
Affix Seal Here
Waiver
I hereby authorize all institutions, my references, employers past and present, business and professional associations, and all private,
personnel and government agencies or instrumentalities (local, state, federal and foreign) to release to the Hearing Aid Dispensers
Examining Committee, any information which is material to my application.
I have carefully read the questions in this application and have answered them completely, without reservations of any kind, and declare
under penalty of perjury that my answers and all statements made by me herein are true and correct and that I am the person referred to
in this application.
Should I intentionally furnish any false information in this application, I hereby agree that such acts shall constitute cause for denial,
suspension or revocation of my license to practice as an Hearing Aid Dispenser in the State of New Jersey.
I have read the above and understand the same.
__________________________________________________
Signature of applicant
Sworn and subscribed to before me this___________________
day of_ ____________________________ , _______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
Affix Seal Here
Official Use Only
Official Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
Resubmit
________________________
New Jersey Office of the Attorney General
License Type 2
________________________
Applicant’s Number
________________________
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
P.O. Box 45038
Newark, New Jersey 07101
(973) 504-6331
Board or Committee
________________________
Certification and Authorization Form
For a Criminal History Background Check
Directions: Answer all of the questions on this form.
1. Name
Mr.
Mrs. __________________________________________________________ (_ ________________________)
Ms.
Last First Middle
Maiden Name
2. Address ____________________________________________________________________________________________
Street or P.O. Box
3. Date of birth __ __ /__ __ /__ __
Month
Day Year
City
Sex:
Male
State
Female
ZIP code
4. Social Security number __________/______ /_ ________
5. Have you completed the fingerprinting process for any Board or Committee of the New Jersey Division of Consumer
Yes
No
Affairs since November 2003?
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history record background
check process. No payment is necessary as of now.
If “Yes,” please provide the following information and follow the instructions outlined below:
________________________________________________
Board or committee requiring the fingerprinting
________________________________________________
Month and year you were fingerprinted
If you were fingerprinted after November 2003 as part of the criminal history background process for licensure or
certification by any other Board or Committee of the New Jersey Division of Consumer Affairs (a background check
conducted for the Department of Education, another state agency or another state does not apply) you will not be required to
be fingerprinted a second time. However, the Division must perform a criminal history background check each time you apply
for licensure or certification. The fee for this service is $22.55. Payment should be made in the form of a check or money
order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor traffic offenses such as a parking or speeding
Yes
No
violations need not be listed.)
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and filed.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within five (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Continuation on the reverse side ➨
Certification
I,_ ______________________________________________, in making this application to the Board or Committee for
certification or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufficient to deny certification or licensure or to withhold renewal of or suspend or revoke a certificate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualifications for certification or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, files or records
requested by the Board or Committee.
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.
__________________________________________________________
__________________________________
Signature of applicant Date
Rev. 4/19/12
New Jersey Office of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
Hearing Aid Dispensers Examining Committee
124 Halsey Street, 6th Floor, P.O. Box 45038
Newark, New Jersey 07101
(973) 504-6331
Hearing Aid Dispensers Examining Committee
Sponsor’s Affidavit
Please complete and return this affidavit with the completed application.
I hereby affirm that I am currently licensed and registered to practice hearing aid dispensing in New Jersey. I have been actively
practicing in New Jersey continuously since _____________. Pursuant to N.J.S.A. 45:9A-16b, N.J.A.C. 13:35-8.3 and N.J.A.C.
13:35-8.6, I hereby agree to assume full responsibility for the supervision and training of _____________________________
upon receipt of a Training Permit, in the requisite skills, methods and techniques so as to insure competency in the fitting and
dispensing of hearing aids. The applicant will train FULL TIME PART TIME* at my business location. I will assume
full responsibility for and guarantee the trainee’s activities in the selling, testing, fitting and dispensing of the hearing aids.
Pursuant to N.J.S.A. 45:9A-16a and N.J.A.C. 13:35-8.5 and 8.6, I will assume full responsibility for and guarantee the temporary
license of _____________________________ and his/her supervision, training and activities in the selling, fitting and dispensing of
hearing aids.
_______________________________________________________
Business Name
_________________________________
Telephone number (include area code)
________________________________________________________________________________________________________
Street Address
City
State
Zip Code
The firm’s Supervising Licensee’s name (N.J.A.C. 13:35-8.8)
_______________________________________________________
Name
The sponsor must enclose copies of his/her original N.I.H.I.S. certificates indicating the completion of a minimum of 20 continuing
education course hours during the PREVIOUS BIENNIAL REGISTRATION PERIOD.
____________________________________________________ ______________________ ________________________
Date
License Number
Sponsor’s Signature
Sworn and subscribed to before me this
day of __________________________ , _____________
________________________________
License number
Month Year
_______________________________________________
Name of Notary Public (please print)
_______________________________________________
Signature of Notary Public
Affix Seal Here
