Click here to download the questionnaire to ensure you are filing the correct application.
In order to expedite the issuance of registrations, the following instructions are being provided for those who wish to apply
for registration as a health care services firm.
Important Note: Please be advised that any application that is missing required information will be rejected. The entire application must be completed and notarized. All of the requested documentation must be submitted with the application.
In order to expedite the issuance of registrations, the following instructions are being provided for those who wish to apply
for registration as a health care services firm.
1. Provide the name of the business. This name must match the name on the corporate, alternate name and trade name documents, the insurance certificate and the bond (if required).
2. Provide any other name under which the applicant does business.
3. Indicate the type of business this is by putting a check in the appropriate box.
4. Provide the street address and the telephone number for the primary location of the business. If the business has more than one primary location, a separate application must be completed. A separate application must be filled out for all health care companies related through joint ownership, boards of directors, officers or principals.
5. Provide the business’ mailing address.
6. Provide the name, business and residence address and telephone number of the business’ registered agent if applicable. If the managing agent is a corporation, association or another company, provide its name, street address and telephone number, and the name and residence address of each of its officers and directors.
7. Indicate the business’ net worth and attach to the application the required insurance certificate(s) and the original bond. If required, provide a certified financial report.
8. Provide the business’ Federal Employer Identification Number.
9.(a-d) Answer these questions ONLY if the business is a sole proprietorship.
10. Provide the name, business and residence address, and telephone number of every officer, director and principal and anyone who holds an ownership interest of 10% or more of the health care services firm. If the owner is a general partnership, every partner must provide the requested information. Every individual responding to this question must indicate the percentage of ownership held.
11. Provide a signed and notarized affidavit from every officer, director, partner, principal and owner indicating whether he/she has ever been convicted of a crime. (See page 6 of the application.)
12. Provide a copy of the New Jersey license of the Health Care Practitioner Supervisor, Registered Nurse or Licensed Physician employed by the agency.
Payment of the Registration Fee: The fee to register as a health care services firm is $500 for each primary location. Payment must be submitted with the application. The certified check or money order should be made payable to the New Jersey Division of Consumer Affairs.2. Provide any other name under which the applicant does business.
3. Indicate the type of business this is by putting a check in the appropriate box.
4. Provide the street address and the telephone number for the primary location of the business. If the business has more than one primary location, a separate application must be completed. A separate application must be filled out for all health care companies related through joint ownership, boards of directors, officers or principals.
5. Provide the business’ mailing address.
6. Provide the name, business and residence address and telephone number of the business’ registered agent if applicable. If the managing agent is a corporation, association or another company, provide its name, street address and telephone number, and the name and residence address of each of its officers and directors.
7. Indicate the business’ net worth and attach to the application the required insurance certificate(s) and the original bond. If required, provide a certified financial report.
8. Provide the business’ Federal Employer Identification Number.
9.(a-d) Answer these questions ONLY if the business is a sole proprietorship.
10. Provide the name, business and residence address, and telephone number of every officer, director and principal and anyone who holds an ownership interest of 10% or more of the health care services firm. If the owner is a general partnership, every partner must provide the requested information. Every individual responding to this question must indicate the percentage of ownership held.
11. Provide a signed and notarized affidavit from every officer, director, partner, principal and owner indicating whether he/she has ever been convicted of a crime. (See page 6 of the application.)
12. Provide a copy of the New Jersey license of the Health Care Practitioner Supervisor, Registered Nurse or Licensed Physician employed by the agency.
Important Note: Please be advised that any application that is missing required information will be rejected. The entire application must be completed and notarized. All of the requested documentation must be submitted with the application.
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