NJ "State Conduct Verification" Application
THE APPLICANT MUST ANSWER THE BELOW QUESTIONS TO BE USED TO ENSURE COMPLIANCE WITH THE STATE OF NEW JERSEY P..L. 2018, c.5 LAW.  

NEW JERSEY SEXUAL MISCONDUCT/CHILD ABUSE DISCLOSURE RELEASE P.L. 2018, c.5
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Email *
TODAY's Date *
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DD
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YYYY
Employer's Name (SELECT ONE): *
YOUR First Name *
YOUR Last Name *
Any Former Names (if applicable) (If N/A, place N/A on the line) *
YOUR Complete Home Address (House #, Street, City, State, Zip Code) *
Last 4 Digits of your Social Security Number *
YOUR Email *
YOUR Telephone number *
Answer Question #1: Have you been the subject of any child abuse or sexual misconduct investigation by any employer, State licensing agency, law enforcement agency, or the Department of Children and Families unless the investigation resulted in a finding that the allegations were false or the alleged incident of child abuse or sexual misconduct was not substantiated? *
Answer Question #2: Have you been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or otherwise separated from any employment while allegations of child abuse or sexual misconduct were pending or under investigation, or due to an adjudication or finding of child abuse or sexual misconduct; *
Answer Question #3: Have you had a license, professional license, or certificate suspended, surrendered, or revoked while allegations of child abuse or sexual misconduct were pending or under investigation, or due to an adjudication or finding of child abuse or sexual misconduct. *
Work/Contract History Section
EMPLOYER NUMBER ONE (If None, write NONE, and skip "Employer Numbers 2 - 15)
Employer Number One's EMPLOYER'S (Business) NAME (Not an individual's name - The Business Name) *
Employer Number One's Street Address, City, State, Zip Code *
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses. *
Employer Number One's Fax Number (if you don't know - Contact them and ask for it) *
Employer Number One's Dates of Employment *
Employer Number One's Position Held *
EMPLOYER NUMBER TWO (If None, write NONE, and skip "Employer Numbers 3 - 15)
Employer Number Two EMPLOYER'S NAME
Employer Number Two Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number Two Fax Number (if you don't know - Contact them and ask for it)
Employer Number Two Dates of Employment
Employer Number Two Position Held
EMPLOYER NUMBER THREE (If None, write NONE, and skip "Employer Numbers 4 - 15)
Employer Number Three EMPLOYER'S NAME
Employer Number Three Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number Three Fax Number (if you don't know - Contact them and ask for it)
Employer Number Three Dates of Employment
Employer Number Three Position Held
EMPLOYER NUMBER FOUR (If None, write NONE, and skip "Employer Numbers 5 - 15)
Employer Number four EMPLOYER'S NAME
Employer Number four Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number four Fax Number (if you don't know - Contact them and ask for it)
Employer Number four Dates of Employment
Employer Number four Position Held
EMPLOYER NUMBER FIVE (If None, write NONE, and skip "Employer Numbers 6 - 15)
Employer Number five EMPLOYER'S NAME
Employer Number five Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number five Fax Number (if you don't know - Contact them and ask for it)
Employer Number five Dates of Employment
Employer Number five Position Held
EMPLOYER NUMBER SIX (If None, write NONE, and skip "Employer Numbers 7 - 15)
Employer Number six EMPLOYER'S NAME
Employer Number six Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number six Fax Number (if you don't know - Contact them and ask for it)
Employer Number six Dates of Employment
Employer Number six Position Held
EMPLOYER NUMBER SEVEN (If None, write NONE, and skip "Employer Numbers 8 - 15)
Employer Number seven EMPLOYER'S NAME
Employer Number seven Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.Employer Number seven Email Address (if you don't know - Contact them and ask for it)
Employer Number seven Fax Number (if you don't know - Contact them and ask for it)
Employer Number seven Dates of Employment
Employer Number seven Position Held
EMPLOYER NUMBER EIGHT (If None, write NONE, and skip "Employer Numbers 9 - 15)
Employer Number eight EMPLOYER'S NAME
Employer Number eight Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number eight Fax Number (if you don't know - Contact them and ask for it)
Employer Number eight Dates of Employment
Employer Number eight Position Held
EMPLOYER NUMBER NINE (If None, write NONE, and skip "Employer Numbers 10 - 15)
Employer Number nine EMPLOYER'S NAME
Employer Number nine Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.Employer Number nine Email Address (if you don't know - Contact them and ask for it)
Employer Number nine Fax Number (if you don't know - Contact them and ask for it)
Employer Number nine Dates of Employment
Employer Number nine Position Held
EMPLOYER NUMBER 10 (If None, write NONE, and skip "Employer Numbers 11 - 15)
Employer Number 10 EMPLOYER'S NAME
Employer Number 10 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number 10 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 10 Dates of Employment
Employer Number 10 Position Held
EMPLOYER NUMBER 11 (If None, write NONE, and skip "Employer Numbers 12 - 15)
Employer Number 11 EMPLOYER'S NAME
Employer Number 11 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number 11 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 11 Dates of Employment
Employer Number 11 Position Held
EMPLOYER NUMBER 12 (If None, write NONE, and skip "Employer Numbers 13 - 15)
Employer Number 12 EMPLOYER'S NAME
Employer Number 12 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number 12 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 12 Dates of Employment
Employer Number 12 Position Held
EMPLOYER NUMBER 13 (If None, write NONE, and skip "Employer Numbers 14 - 15)
Employer Number 13 EMPLOYER'S NAME
Employer Number 13 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.Employer Number 13 Email Address (if you don't know - Contact them and ask for it)
Employer Number 13 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 13 Dates of Employment
Employer Number 13 Position Held
EMPLOYER NUMBER 14 (If None, write NONE, and skip "Employer Numbers 15)
Employer Number 14 EMPLOYER'S NAME
Employer Number 14 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number 14 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 14 Dates of Employment
Employer Number 14 Position Held
EMPLOYER NUMBER 15 (If None, write NONE)
Employer Number 15 EMPLOYER'S NAME
Employer Number 15 Street Address, City, State, Zip Code
Employer Number One's Email Address (if you don't know - Contact them and ask for it)

IMPORTANT: Your application will NOT be processed without a VALID email address.  Websites are not email addresses.
Employer Number 15 Fax Number (if you don't know - Contact them and ask for it)
Employer Number 15 Dates of Employment
Employer Number 15 Position Held
By providing your electronic signature below, the applicant understands that if the applicant provides false information or willfully fail to disclose material information required by this form the applicant will be subject to professional discipline up to and including termination and denial of employment, and any other criminal or civil penalties in accordance with state law and regulations.  The applicant hereby authorizes the employer named on this form to release the requested information, and any other information permitted by law, to the entity listed below.  The applicant release, waive and discharge the employer identified on this form and the entity named below from any and all liability of any kind that may arise from the disclosure and use of the information provided on this form.
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Confirmation & Certification
If confirmed, please check the box below. *
Electronic Signatures. The Parties agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.
Write YOUR FULL NAME which will serve as your Electronic Signature *
Questions can be emailed to: RVerry@GrayLawGroup.com
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