Application for Licensure as a Clinical Alcohol and Drug Counselor

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   Attach two, full-face passport-                                                                           Written Examination
   style photographs (2x 2) of your                                                                          Oral Examination
   head and shoulders, taken within                                                                          Written and Oral Examinations
   the past six months.                                                                                         _________________
                                                    New Jersey Office of the Attorney General                           Date exam passed
   Two photographs are required                               Division of Consumer Affairs
   with each application.                        State Board of Marriage and Family Therapy Examiners  Certified Alcohol and
                                                        Alcohol and Drug Counselor Committee           Drug Counselor (C.A.D.C.)
   Do not use staples to attach the                   124 Halsey Street, 6th Floor, P.O. Box 45040
   photographs.
                                                              Newark, New Jersey 07101                 Licensed Clinical
                                                                     (973) 504-6582                    Alcohol and Drug 
                                                                                                               Counselor (L.C.A.D.C.)

      Application for Licensure as a Clinical Alcohol and Drug Counselor or
                 Certification as an Alcohol and Drug Counselor
                                                                                                Date:


A nonrefundable application filing fee of $75, in the form of a check or money order made out to the State of New Jersey, must be submitted
with this application. (Applicants should understand that if the application filing fee is 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 fee is paid.)
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. Your "address of record" is the address that will be made available to the public on the Online Licensee Directory.
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.

Personal Information
                 Mr.
1.  Name         Mrs. _ ____________________________________________________________ (_______________________)
                 Ms.         Last name              First name         Middle initial          Maiden name


2. Address
        Home:__________________________________________________________________________________________
                    Street or P.O. Box                                   City          State                ZIP code                County


                ____________________________________                                            __________________________________
                                  Telephone number (include area code)                                                 E-mail address


        Business:________________________________________________________________________________________
                                         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
     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 or certificate unless you provide the
     required documents concerning the plan for payment 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 your licensure or certification.

    ____________________________________                _ ___________________________________               _________________________
               Applicant's name (please print)                             Applicant's signature                            Date




                                                                     -2-
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 self-incrimination.
    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 an alcohol and drug counselor" is to be construed to include all of the following:
    a. The cognitive capacity to exercise reasonable alcohol and drug counselor judgments and to learn and keep abreast of
       professional developments; and
    b. The ability to communicate those judgments and related information to clients 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 an alcohol and drug counselor, 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 treat-
       ment (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.

     _ ____________________________________________________                                  ___________________________________
                                 Applicant's signature                                                          Date


                                                                  -3-
8. Have you previously applied for a license or certificate as an Alcohol and Drug Counselor in New Jersey, any other state, the District
   of Columbia or in any other jurisdiction?                                                                        Yes         No
   If "Yes," when? ________________________________________
9. Have you ever passed an oral and/or written alcohol and drug counseling examination in New Jersey, any other state, the District of
   columbia or in any other jurisdiction?                                                                        Yes        No
   If "Yes," please attach a copy of your examination scores to this application.
10. 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
11. 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.)
12. 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 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                  State or jurisdiction that issued the license or certificate           Date issued/expired


    ______________________                 ________________________      ____________________________                                       _____________________
          Type of license or certificate             Number                  State or jurisdiction that issued the license or certificate           Date issued/expired


    ______________________                 ________________________      ____________________________                                       _____________________
          Type of license or certificate             Number                  State or jurisdiction that issued the license or certificate           Date issued/expired


    ______________________                 ________________________      ____________________________                                       _____________________
          Type of license or certificate             Number                  State or jurisdiction that issued the license or certificate           Date issued/expired


    ______________________                 ________________________      ____________________________                                       _____________________
          Type of license or certificate             Number                  State or jurisdiction that issued the license or certificate            Date issued/expire




13. Have you ever been disciplined or denied 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
14. Have you ever had a professional license or certificate of any type suspended, revoked or surrendered in New Jersey, any other
    state, the District of Columbia or in any other jurisdiction?                                              Yes   No
15. 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
16. Have you ever been named as a defendant in any litigation related to the practice of alcohol and drug counseling or other
    professional practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?      Yes   No
17. 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
18. 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
19. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
    related to the practice of alcohol and drug counseling 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 13 through 19, is "Yes," provide a complete explanation of the circumstances
    leading to the action, and any supporting documentation, on separate sheets of paper.


                                                                       -4-
Education
1. What is the name and address of the high school you attended?_
                                                                _____________________________________________________
                                                                                                                    Name of high school

    ________________________________________________________________________________________________________
                                   Street address                                          City                    State /Country                 ZIP code



2. What years did you attend high school?_ _____________________

3. Did you graduate from high school?                               Yes             No

    If "Yes," what was the date of your graduation?_______________________________
                                                                               Month               Year

    If "No," did you study to receive a G.E.D. certificate?                              Yes                  No

    If "Yes," please provide the name and address of the educational institution that issued your G.E.D. certificate and the date
    the certificate was issued.

    ________________________________________________________________________________________________________
                                                                            Name of educational institution

    ________________________________________________________________________________________________________
                                   Street address                                          City                    State                   ZIP code

    ________________________________________________________________________________________________________
                           Date certificate was issued



4. What is the name and address of the colleges or universities you have attended?

       a)
                                                                          Name of college or university

    
                             Street address                                                City                        State                     ZIP code
       b)
                                                                          Name of college or university


                             Street address                                                City                        State                     ZIP code
       c)
                                                                          Name of college or university


                             Street address                                                City                        State                     ZIP code
       d)
                                                                          Name of college or university


                             Street address                                                City                        State                     ZIP code



5. List all of the degrees that you have received from recognized colleges or universities. Please have each college or university forward
   to the Committee the official transcript for each degree that you have earned. (See page 7.)


            Educational institution                       Inclusive years              Title of Degree,            Major                   Date granted
                                                                                         Diploma or
                                                                                         Certificate

 ________________________                                _ ____________                ____________  ____________                      _______________________

 ________________________                                _ ____________                ____________  ____________                      _______________________

 ________________________                                _ ____________                ____________  ____________                      _______________________

 ________________________                                _ ____________                ____________  ____________                      _______________________




                                                                                    -5-
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