Application # _______________ For NJDEP use only

State of New Jersey
LICENSED SITE REMEDIATION PROFESSIONAL LICENSURE EXAMINATION APPLICATION WITH
Department of Environmental Protection Site Remediation Program

FULL CREDENTIAL REVIEW

Site Remediation Professional Licensing Board

Date Stamp (For Department use only)

1. APPLICANT INFORMATION (All forms must be typed) Name Dr. Last Name: First Name: Maiden Name Will the NJDEP receive information about you under a different name?. If your answer is “Yes,” fill in that name below: Dr. Last Name: First Name: Maiden Name: Mailing Address Mailing Address: City: County: State: E-Mail /Internet Address: M.I.: Ms. Mrs. Mr. Yes No M.I.: Ms. Mrs. Mr.

A photo is required with each application. Attach a clear, fullface passport-style photograph (2" x 2") of your head and shoulders, taken within the past six months. (Attach Photo Here) Applicants should write their full name on the back of the photo. Do not staple or clip to attach the photo. Please use double sided tape.

Zip Code:

Business Address Check if same as Mailing Address Business Name: Business Address: City: County: State: E-Mail /Internet Address: Business Mailing Zip Code:

Please indicate the address you would like the NJDEP to use for all correspondence and billing by placing an “X” in the appropriate box: .......................................................................... Telephone Number(s): Daytime: Cellular: Please indicate the telephone number(s) you would like the NJDEP to use by placing an “X” in the appropriate box: ........................................................................

Other: Daytime Cellular Yes..... Other No

Are you in need of an exam administration modification due to a disability covered under the Americans with Disabilities Act ......................................................................................................... 2. RELEVANT TRAINING AND COURSEWORK

For items a through c below, please provide the location, date, and course provider for the listed training courses. Provide a copy of the course completion certification for each of the courses listed below. Evidence of course completion is required and without this information, your application will be rejected. a. 40-hour health & safety training pursuant to 29 CFR 1910.120 (attach course completion certification)
___________________________________________ _______________________________________________ ____________________________

Course Provider
LSRP Examination Application With Full Credential Review Version 1.2 03/01/12

Course Location

Date of Training
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b. 8-hour refresher training course pursuant to 29 CFR 1910.120 (attach course completion certification)
___________________________________________ _______________________________________________ ____________________________

Course Provider

Course Location

Date of Training

c. SRPLB/NJDEP approved course on the State’s rules & regulations concerning the Technical Requirements for Site Remediation (attach course completion certification)
___________________________________________ _______________________________________________ ____________________________

Course Provider

Course Location

Date of Training

d. Please list any professional certifications and licenses you currently hold and provide proof of licensure. Date Issued Agency/State Issuing License Date License Expires

License Description

License Number

e. Please attach an updated resume. 3. QUALIFYING DEGREE: Based on the Minimum Education Requirements in the Site Remediation Reform Act, provide information about the qualifying education: Official transcript(s) must be submitted with all degrees in qualifying area(s) of study. An official transcript with the applicant’s name on the envelope must be submitted with the application, the official transcript must be submitted in the envelope unopened with the application as received directly by the institution. This requirement also applies to applicants educated in foreign countries. Qualifying Degree and Degree type: __________________________________________ Year Graduated: _____________ School Name: ______________________________________________ Location: ____________________________________ Transcript: attached mailed separately

Additional education information must be included for all degrees to be used as a substitution of Professional Experience. Qualifying Degree and Degree type: __________________________________________ Year Graduated: _____________

School Name: ______________________________________________ Location: ____________________________________ Transcript: attached mailed separately Year Graduated: _____________

Qualifying Degree and Degree type: __________________________________________ Transcript: attached mailed separately

School Name: _______________________________________________ Location: ____________________________________

Qualifying Degree and Degree type: __________________________________________ Transcript: attached mailed separately

Year Graduated: _____________

School Name: _______________________________________________ Location: ____________________________________

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4. MORAL CHARACTER AND PROFICIENCY: a. Have you ever been disbarred, suspended, reprimanded, censured or otherwise disciplined as a member of any profession or holder of any public office, or have you voluntarily surrendered a professional license? ........................................................................................ If “Yes,” explain the circumstances on a separate page. b. Are you currently a defendant in a criminal proceeding? .......................................................................... If “Yes,” explain the circumstances on a separate page. c. Are you currently the subject of pending professional disciplinary proceedings? ..................................... If “Yes,” explain the circumstances on a separate page. d. Convictions, Judgments and Settlements: (i) Have you ever been convicted of, or plead guilty to, an environmental crime, or any similar or related criminal offense under federal or state law, or any crime involving fraud, theft by deception, forgery, or any similar or related criminal offense under federal or state law?...... If “Yes,” explain the circumstances on a separate page. (ii) Have you ever had a professional license revoked by any state licensing board or any other professional licensing agency within the previous 10 years? .............................................................. If “Yes,” explain the circumstances below. Attach additional pages if needed.

Yes Yes Yes

No No No

Yes

No

Yes

No

5. SOCIAL SECURITY NUMBER: You must disclose your Social Security number for the reasons stated below. Failure to do so may result in a denial of your application. Pursuant to N.J.S.A. 2A:17-56.44e of the New Jersey child support enforcement law, N.J.S.A. 54:50-25 of the New Jersey taxation law and Section 1128 E(b)(2)A of the Social Security Act, the NJDEP or licensing agency to which this form is submitted is required to obtain your Social Security number. If you do not have a Social Security number, the NJDEP must ascertain the reason that you do not have one. The NJDEP is further obligated to provide your Social Security number to the Director of Taxation, the Probation Division or other agency responsible for child support enforcement and the H.I.P. Data Bank when reporting adverse actions. You are also being asked to consent, on a voluntary basis, to the use of your Social Security number for the additional reasons stated below. You are notified that under the Federal Privacy Act (5 U.S.C. Section 552a (note (b)), the NJDEP or licensing agency to which this form is submitted is requesting the voluntary disclosure of your Social Security number. If you give your consent for the use of your Social Security number, it may be used: to verify the identity of an applicant, to aid in the collection of financial obligations due and owing the NJDEP or any other state agency, and to aid in the disclosure to state or federal law enforcement and licensing officials and agencies of information obtained in investigations pertaining to licensure or certification and disciplinary proceedings. SNN: _______________________________ I, ___________________________________________ on _________________ , Applicant’s signature Date Consent Do Not Consent

to the use of my Social Security number for any of the additional purposes set forth above. I understand that without my consent and this information, my application will be denied. 6. CITIZENSHIP / IMMIGRATION STATUS (pursuant to 8 U.S.C. 1621) Please certify, under penalty of perjury, the following: 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 Bureau of Citizenship and Immigration Services (B.C.I.S.).

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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 B.C.I.S. at: 1-800-375-5283. 7. CHILD SUPPORT (pursuant to N.J.S.A. 2A:17-56.44e) Please certify, under penalty of perjury, the following: a. Do you currently have a child-support obligation?.................................................................................... (1) If “Yes,” are you in arrears in payment of said obligation? .................................................................. (2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? .... b. Have you failed to provide any court-ordered health insurance coverage during the past six months? .. c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? ... d. Are you the subject of a child-support-related arrest warrant? ................................................................ Yes Yes Yes Yes Yes Yes No No No No No 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 this application. Furthermore, any false certification of the above may subject you to a penalty, including, but not limited to, immediate revocation or suspension of licensure. ________________________________________ Applicant’s name (please print) _________________________________________ Applicant’s signature _____________________ Date

8. CERTIFICATION AND HANDWRITING SAMPLE THIS PART MUST BE HAND WRITTEN: Please write the following statement in the space provided below. The statement must be completed in black ink in your usual handwriting. "I certify under penalty of law that the information provided in this document is true, accurate and complete to the best of my knowledge and belief. I am aware that there are significant civil penalties for knowingly submitting false, inaccurate or incomplete information and that I am committing a crime of the fourth degree if I make a written false statement which I do not believe to be true. I understand that any misrepresentation will constitute grounds for rejection of my application for licensure.”

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Application # _______________ For NJDEP use only

Applicant Signature:

Date:

9. CERTIFICATION OF 5,000 HOURS OF RELEVANT PROFESSIONAL EXPERIENCE I certify under penalty of law that I have met the minimum requirement of having 5,000 hours of relevant professional experience within the State over the five (5) years immediately prior to submission of this application, that is of professional grade and character that indicates I am competent to issue a response action outcome (N.J.S.A. 58: 10C-7.d(3)) Applicant Signature ________________________________________ 10. AFFIDAVIT This affidavit is to be executed by the applicant before a notary public: State of: County of: I, , in making this application to the Department of Environmental Protection (NJDEP) on Behalf of the New Jersey Site Remediation Professional Licensing Board (Board) for licensure under the provisions of N.J.S.A. 58:10C-1 et seq. of the Site Remediation Reform Act, swear (or affirm) that I am the applicant and that all information provided in connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufficient to deny licensure or to withhold renewal of or suspend or revoke a license certificate issued by the NJDEP. I further swear (or affirm) that I have read the Site Remediation Reform Act (N.J.S.A. 58: 10C-1 et seq.) and fully understand that in receiving licensure from the NJDEP, I bind myself to be governed by the Site Remediation Reform Act. Furthermore, I voluntarily consent to a thorough investigation of my past and present employment and other activities for the purpose of verifying my qualifications for licensure. I further authorize all institutions, employers, agencies, and all governmental agencies and instrumentalities (local, state, federal and foreign) to release any information, files, or records requested by the NJDEP. Finally, I understand to obtain a license from the Board, I must fulfill all requirements of the licensing Board and satisfactorily pass the examination. Date: _________________

Applicant’s signature Sworn and subscribed to me this day of Month , Year

Name of Notary Public (please print)
Affix Seal Here

Signature of Notary Public
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11. PROFESSIONAL EXPERIENCE/PROJECT HISTORIES – List projects where you applied scientific or engineering principles to contaminated site remediation and where the resulting conclusions formed the basis for reports, studies or other documents connected with the remediation of the site or project site. 11a. Professional Experience in New Jersey – Please list the most recent projects first. Duration of Involvement in Project (Month/Year) to to to to to to to to to to to to Estimated Identify the Check if Hours of Remedial Phase Detailing in Professional for the Project Project History Experience (SI, RI, RA) (11d)

Project # 1 2 3 4 5 6 7 8 9 10 11 12

Project Name

NJDEP Program Interest Number

Municipality/County

Total Estimated Hours of Professional Experience in New Jersey (Must equal or exceed 5 years of full-time experience, 3 of which shall have occurred immediately prior to submission of this application.) This table may be copied if additional pages are necessary
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11a. Professional Experience in New Jersey (continued) – Please list the most recent projects first. Duration of Involvement in Project (Month/Year) to to to to to to to to to to to to to Total Estimated Hours of Professional Experience in New Jersey (Must equal or exceed 5 years of full-time experience, 3 of which shall have occurred immediately prior to submission of this application. This table may be copied if additional pages are necessary
LSRP Examination Application With Full Credential Review Version 1.2 03/01/12

Project #

Project Name

NJDEP Program Interest Number

Municipality/County

Estimated Identify the Check if Hours of Remedial Phase Detailing in Professional for the Project Project History Experience (SI, RI, RA) (11d)

Check here if using additional pages and add totals at end.
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11b. Professional Experience Outside of New Jersey – Please list the most recent projects first. Identify the Estimated Hours Remedial Phase of Professional for the Project Experience (SI, RI, RA)

Project # 1 2 3 4 5 6 7 8 9 10 11 12 13

Project Name

State/Federal Project Tracking #

Municipality/State

Duration of Involvement in Project (Month/Year) to to to to to to to to to to to to to

Total Estimated Hours of Professional Experience outside of New Jersey This table may be copied if additional pages are necessary
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11b. Professional Experience Outside of New Jersey (continued) – Please list the most recent projects first. Identify the Estimated Hours Remedial Phase of Professional for the Project Experience (SI, RI, RA)

Project #

Project Name

State/Federal Project Tracking #

Municipality/State

Duration of Involvement in Project (Month/Year) to to to to to to to to to to to to to

Total Estimated Hours of Professional Experience outside of New Jersey This table may be copied if additional pages are necessary
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11c. Total Professional Experience Total Estimated Hours of NJ Professional Experience (from 11a above) Total Estimated Hours of Professional Experience Outside of NJ (from 11b above) Qualifying Higher Education Professional Experience Substitution Total Estimated Hours of Professional Experience (Must equal or exceed 8,000 hours)

11d. Project History – Project History # (from 11a): Project Name: Project Location Address: NJDEP Program Interest #: Project Duration: Start Date: Time you are claiming Professional Experience for this project: Project Client: Client Contact: Client Address: Client Phone: Position on Project: Identify the remedial phases where you were the principal decision maker (check all that apply): Site Investigation: .............. Soils .................... Groundwater ....... Remedial Investigation: .... Soils .................... Groundwater ....... Remedial Action: ............... Soils .................... Groundwater ....... Yes Yes Yes Yes Yes Yes No No No No No No End Date: Start Date: (if applicable) End Date:

This table may be copied if additional pages are necessary.

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11d. Project History (continued) – Project History # (from 11a):

_______

In 1,000 words or less, please provide details or a detailed description of your responsibility associated with this project in relation to the experience noted in table 11a. Briefly describe the nature and extent of the environmental complexity associated with this project, including the class of contaminants and affected media. Please detail how you applied scientific or engineering principles to contaminated site remediation where the resulting conclusions formed the basis for reports, studies or other documents connected with the remediation of this project.

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