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Requires a passport-style photo taken within the past six months, correct fee payment of $75, and clear completion of all questions. Collects personal data including name, addresses, Social Security number, citizenship/immigration status, and child-support related certifications. 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If the place of residence is used as the public address of record, consent is assumed; if not consenting, provide an address other than your residence. One address must include street, city, state, and ZIP code.",{"name":119,"@type":110,"acceptedAnswer":120},"What information is required for Social Security compliance?",{"text":121,"@type":113},"You must provide your Social Security number to the Board or Committee; failure to do so results in denial or nonrenewal of licensure or certification. The form also describes statutory authorities for obtaining and sharing the Social Security number with specified agencies.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},330299,1790645737,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":29,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":145},1374391974468,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Attach a clear, full-face passportstyle photograph (2˝x 2˝) of your head and shoulders, taken within the past six months.  \nA photo is required with each application.  \nDo not use a paper clip to attach the photo.  \nNew Jersey Office of the Attorney General  \nDivision of Consumer Affairs State Board of Social Work Examiners  \n124 Halsey Street, 6th Floor, P.O. Box 45033 Newark, New Jersey 07101  \n(973) 504-6495  \nWebsite: [http://www.njconsumeraffairs.gov/social/](http://www.njconsumeraffairs.gov/social/)  \nFor Office Use Only  \nApplication for Licensure as a Licensed Clinical Social Worker Pursuant to N.J.S.A. 45:15BB-6 / N.J.A.C. 13:44G-4.1  \nDate:    \nAnonrefundable 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.)  \nThe Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their consent . However, you are required to provide an address that may be released to the public in our directories or in response to other requests (by putting a check in the appropriate box) . If you provide your place of residence as your public address of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of your place of residence, you should provide an address of record other than your place of residence that may be released to the public. One of your addresses must include a street, city, state and ZIP code.  \nInformation that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA) .  \nPlease print clearly. You must answer all of the questions on this application.  \nPersonal Information Date ofbirth:    \nMonth Day Year  \n Mr.  \n1. Name  Mrs   (   )  \n Ms. Last name First name Middle initial Maiden name  \n2. Address  \n Home:   Street or P.O. Box City State ZIP code County  \nTelephone number (include area code) E-mail address  \n Business:    \nName of company Telephone number (include area code) and extension  \n____________________________________________________________________________________________  \nStreet City State ZIP code County  \n Mailing:    \nStreet or P.O. Box City State ZIP code County  \n3. Social Security Number  \nYou must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of licensure or certification.  \n*Social Security Number:   -  -    \n*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:  \na . 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;  \nb. the Probation Division or any other agency responsible for child support enforcement, upon request; and  \nc . the National Practitioner Data Bank and the H.I.P. Data Bank, when reporting adverse actions relating to health care professionals.  \n4. Citizenship / Immigration Status  \nFederal 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 al","cbCaieOypPiL3zen","https://ap.wps.com/l/cbCaieOypPiL3zen","pdf",1260620,14,"English","# Required submission details\n## Passport-style photograph\n## Application fee\n## Public address disclosure and OPRA\n# Personal information\n## Name and date of birth\n## Addresses and contact details\n## Social Security number\n# Eligibility questions\n## Citizenship / immigration status\n## Child support certifications\n## Illegal use of controlled dangerous substances","[{\"question\":\"What materials must be submitted with the application?\",\"answer\":\"A passport-style full-face photograph of the head and shoulders (2˝x 2˝) taken within the past six months is required with each application, and a nonrefundable $75 fee must be submitted by check or money order payable to the State of New Jersey.\"},{\"question\":\"How are addresses handled for public disclosure?\",\"answer\":\"An address that may be released to the public must be provided. If the place of residence is used as the public address of record, consent is assumed; if not consenting, provide an address other than your residence. One address must include street, city, state, and ZIP code.\"},{\"question\":\"What information is required for Social Security compliance?\",\"answer\":\"You must provide your Social Security number to the Board or Committee; failure to do so results in denial or nonrenewal of licensure or certification. The form also describes statutory authorities for obtaining and sharing the Social Security number with specified agencies.\"}]","NJ-LCSW-Application - Application for Licensure as a Licensed Clinical Social Worker | PDF",1789988053,35]