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Certification And Authorization Form For A Criminal History Background Check NJBOS-8 - New Jersey
| Certification And Authorization Form For A Criminal History Background Check Form. This is a New Jersey form and can be used in Securities Blue Sky Secretary Of State . |
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New Jersey Office of the Attorney General Division of Consumer Affairs Bureau of Securities P.O. Box 47029 Newark, New Jersey 07101 CertifiCation and authorization form for a Criminal history BaCkground CheCk Directions: Please complete all of the sections on this form. 1. Name Dr. Mr. _________________________________________________________ ( ________________________) Mrs. LastFirstMiddle Maiden Name (if applicable) Ms. Street or P.O. Box City State ZIP code 2. Mailing Address ___________________________________________________________________________________________ (You MUST use the mailing address on file as it appears on the Form U4. If this address is not current, please amend your Form U4 as soon as possible so that there is no delay in the background check process.) 3. Date of birth __ __ /__ __ /__ __ Month Day Year 4. Sex: Male Female 5. Daytime telephone number___________________ (Include area code) 6. Social Security number _________/ _____ / ________ 7. CRD or state registration number ________________________ 8. Have you completed the fingerprinting process for the New Jersey Bureau of Securities since November 2003? Yes No If "Yes," please provide the date on which you were fingerprinted: __ __ /__ __ /__ __ __ __ If you were fingerprinted after November 2003 as part of the criminal history background process for registration for the Bureau of Securities or the New Jersey Division of Consumer Affairs, you will not be required to be fingerprinted a second time. You must complete this Certification and Authorization form and include the date that you were fingerprinted. 9. Have you ever been arrested and/or convicted of a crime or offense? (Minor traffic offenses such as a parking or speeding violations need not be listed.) Yes No 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. 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. It is your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Bureau of Securities within thirty (30) days if you are convicted of any crimes or offenses after this form has been completed. Month Day Year Continuation on the reverse side American LegalNet, Inc. www.FormsWorkFlow.com CertifiCation I, ______________________________________________,certifythatalloftheinformationprovidedonthisformistruetothe (Please print full name.) bestofmyknowledgeandbelief.Iunderstandthatanyomissions,inaccuraciesorfailuretomakefulldisclosuresmaybedeemed sufficienttowithholdrenewalof,revoke,suspendorrestrictaregistrationissuedbytheBureauofSecurities. IherebyacknowledgethattheBureaumayapprovemyregistrationinadvanceofreceivingtheresultsofmyCriminalHistory BackgroundCheck.Shouldanyinformationbereturnedthatwouldhavecausedmyregistrationtobedeniedorsubjectmetoa restrictedregistration,theBureaumayrevoke,suspendorrestrictmyregistrationaccordingly. I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose of verifying my qualifications for registration. 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 requestedbytheBureauofSecurities. Icertifythattheforegoingstatementsmadebymearetrue.Iamawarethatifanyoftheforegoingstatementsmadebymeare willfullyfalse,Iamsubjecttopunishment. __________________________________________________________ _________________________________ SignatureofapplicantDate frequently asked questions I recently had a background check done for another New Jersey agency (e.g. the Department of Banking and Insurance). Do I have to undergo the process again? Yes,becausetheregulationconcerningthedisseminationofcriminalhistoryrecordinformationprohibitsthesharingofthematerial foranyreasonotherthantheauthorizedandintendedpurposeforwhichitwasgathered.(28C.F.R.ยง20;N.J.A.C.13:59-1.1etseq.) What if I previously completed the Certification and Authorization form and have gone through the Criminal History Record Background Check process for the Bureau of Securities? If you have already undergone the Criminal History Record Background Check process for the Bureau of Securities, you mustcompletetheCertificationandAuthorizationformandincludethedateonwhichyouwerefingerprinted. Foracompletelistoffrequentlyaskedquestions,pleasevisitourwebsiteat:www.NJConsumerAffairs.gov/chbcfaq.htm. Rev. 1/23/12 American LegalNet, Inc. www.FormsWorkFlow.com
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