New
J
ersey
Office of the Attorney
Gener
al
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
2. Mailing
Dr.
Mr.
Mrs.
Ms.
( )
Last First Middle Maiden Name (if
applicable)
Address
Street or P.O. Box City
State
ZIP code
3. E-mail Address: Investment Adviser Issuer Agent
(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.)
4. Date of birth /
/
5. Sex: Male Female 6. Daytime telephone number
Month Day Year (Include area code)
7. Social Security number / /
8. Individual CRD or state registration number
9. Have you completed the fingerprinting process by IDEMIA
/
MorphoTrust for the New Jersey Bureau of Securities or
Division of Consumer Affairs since May 2012?
Yes
No
If “Yes,” please provide the date on which you were
fingerprinted:
/
/
Month Day Year
If you were fingerprinted by IDEMIA
/
MorphoTrust after May 2012 as part of the criminal history background
Process for registration by the Bureau of Securities or the New Jersey Division of Consumer Affairs, you will not
be required to be
fi
ngerprinted a second time. However, a criminal history background check must be performed each
time you apply for registration.
10. 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
E v e r y s u c h c o n v i c t i o n o n r e c o r d m u s t b e d i s c l o s e d . A
t r u e c o p y o f e v e r y p o l i c e r e p o r t , j u d g m e n t o f
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
court 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.
CERTIFICATION
I,
_
,
_
certify
that
all
_
of
_
the
_
information
_
provided
_
on
_
this
_
form
_
is
_
true
_
to
_
the
_
(Please
_
print
_
full
_
name.)
best
of
my
knowledge
and
belief.
I
understand
that
any
omissions,
inaccuracies
or
failure
to
make
full
disclosures
may
be
deemed
sufficient
to
withhold
renewal
of,
revoke,
suspend
or
restrict
a
registration
issued
by
the
Bureau
of
Securities.
I
hereby
acknowledge
that
the
Bureau
may
approve
my
registration
in
advance
of
receiving
the
results
of
my
Criminal
History
Background
Check.
Should
any
information
be
returned
that
would
have
caused
my
registration
to
be
denied
or
subject
me
to
a
restricted
registration,
the
Bureau
may
revoke,
suspend
or
restrict
my
registration
accordingly.
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,
fi
les
or
records
requested
by
the
Bureau
of
Securities.
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
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,
because the
regulation concerning
the
dissemination of
criminal
history
record
information
prohibits
the
sharing
of
the
material
for
any reason other
than
the authorized and intended
purpose for
which it
was
gathered.
(28
C.F.R.
§20;
N.J.A.C.
13:59-1.1
et
seq.)
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
will
not
be
required
to
be
fingerprinted
a
second
time.
However,
you must
complete the
Certification
and
Authorization form,
i
ndicating
the
date
on
which
you
were
fingerprinted,
and
include
a
fee
of
$19.37,
payable
to
the
State
of
New
Jersey,
to
have
your
fingerprints
resubmitted.
For
frequently
asked
questions,
please
visit
our
website
at:
www.njconsumeraffairs.gov/ocp/Documents/CHRU-General-FAQ.pdf
and www.njconsumeraffairs.gov/ocp/Documents/chru_fingerprinting_FAQ.pdf.
Rev.
10/25/23
NJBOS-4
