Motor Vehicle Commission STATE OF NEW JERSEY Business License Services (609) 777-1684 In order to process your Emission Repair Facility (ERF) Registration please submit the items listed below: License Application Supplemental Application (owner, partner(s), officer(s) or member(s) Child Support Certification (owner, partner(s), officer(s) or member(s) $50.00 Registration Certificate fee (make check payable to NJMVC) Emission Repair Technician Form – list all certified technicians Copy of each technician’s New Jersey Repair Technician Certificate issued by NJ Department of Environmental Protection (NJ DEP) Copy of each letter issued to the technician by NJDEP indicating the Emission Repair Technicians (ERT) identification number Copy of driver’s license for the owner, partner(s), officer(s) or member(s) Copy of Incorporation/Formation Papers showing the filing date with the NJ Secretary of State’s Office Copy of Alternate name Filing (if applicable) Business Hours Form Copy of your Certificate of Authority for Sales Tax issued by NJ Division of Taxation Copy of your Federal EIN Registration Certificate issued by the Federal Government or your last Quarterly 941 form A copy of your Unemployment Quarterly Report or a copy of your NJ Unemployment Registration Certificate I certify that the above items are being submitted for the processing of an Emission Repair Facility Registration Certificate. My failure to submit the required documents will be cause for the application package being returned. ______________________________ __________________________ Applicant Print Name Applicant’s Signature ____________________________________________ Business Name _______________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 # 5014 APPLICATION FOR REGISTRATION EMISSION REPAIR FACILITY FEE: $50.00 Corp Code:______________________________ Business Phone____________________ ________________________________________ Name of Business (if corporation, corporate name) _________________________________ NJ Sales Tax Identification No. ________________________________________ Street Address _________________________________ NJ Unemployment Registration No. ________________________________________ City State Zip County _________________________________ Federal Employment Identification No. Complete the following for proprietor, partners, or corporate officers: NAME ADDRESS TITLE _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ FOR OFFICE USE ONLY License Number: _______________________ Approved By: __________________________ BLS-63 (R 9/09) Date: On the Road to Excellence www.njmvc.gov New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com Please indicate the owner, partner(s), corporate officer(s) or possessor who has a controlling interest in the business: Has the applicant(s) ever been convicted of a crime? If yes, please explain. Has the applicant(s)ever been found to be in violation of the Federal Clean Air Act (42 U.S.C. 7401 et. seq.) or the Consumer Fraud Act (N.J.S.A. 56:8-1 et. seq.) or any regulations adopted thereunder or N.J.A.C. 7627-15.7 pertaining to tampering with emission control apparatus? Has the applicant(s) ever been denied, or had suspended or revoked, a license or registration to engage in any business, profession or occupation licensedor registered under the laws of any State? Does the applicant(s) have any interest in any other motor vehicle emission facility or any motor vehicle related businesses? If so, please list name and license number. APPLICANT'S SIGNATURE AND TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS LICENSE SERVICES SUPPLEMENTARY APPLICATION BUSINESS NAME BUSINESS PHONE # 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX, IF ANY 2. STREET ADDRESS CITY STATE HOME PHONE # 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU W E R E IN EACH STATE OR COUNTRY. 5. DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 6. PLACE OF BIRTH: (CITY, STATE OR FOREIGN COUNTRY) 8. HEIGHT 11. SOCIAL SECURITY NUMBER 10. COLOR OF EYES 9. WEIGHT 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: DATE 1. FULL NAME INCLUDING MIDDLE NAME AND SUFFIX. IF ANY 2. STREET ADDRESS CITY STATE 3. HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? HOME PHONE # 4. LIST THE CITIES, STATES OR FOREIGN COUNTRIES WHERE YOU LIVED BEFORE AND HOW LONG YOU WERE IN EACH STATE OR COUNTRY. 5 DATE OF BIRTH (MO. DAY, YEAR) 7. SEX 11. SOCIAL SECURITY NUMBER 6. PLACE OF BIRTH: (CITY. STATE OR FOREIGN COUNTRY) 8. HEIGHT 9. WEIGHT 10. COLOR OF EYES 12. DRIVER LICENSE NUMBER (STATE) 13. HAVE YOU, IN THIS OR ANY OTHER STATE OR COUNTRY EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME, DISORDERLY PERSONS OFFENSE, VIOLATION OF CONSUMER PROTECTION LAWS OR REGULATIONS? YES NO IF YES, ATTACH EXPLANATION DESCRIBING NATURE OF OFFENSE, DATE, CITY AND STATE WHERE OFFENSE OCCURRED, IDENTIFY COURT OR ADMINISTRATIVE TRIBUNAL BEFORE THE CASE WAS TRIED, DATE AND SENTENCE. 14. I CERTIFY THAT THE INFORMATION PROVIDED HEREIN AND ATTACHMENTS, IF ANY, IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE: BLC-205B (R12/03) DATE American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau P.O. Box 171 Trenton, New Jersey 08666-0171 (609) 292-6500 #5014 _______________________________________________________________________________________ CHILD SUPPORT CERTIFICATION FORM _________________________________________ Business Name _________________________________________ Applicant’s Name (Print) __________________ Date of Birth _________________________________________ Social Security Number Under the provisions of N.J.S.A. 2A:17-56.7 et seq., responses to the questions listed below are required. Misstatements will be just cause to take administrative action including, but not limited to, denial of licensure, immediate suspension or revocation of the license. 1. Do you have a child support obligation? Yes No 2. If yes, do the arrearage amounts equal or exceed the amount of child support payable for six months? Yes No 3. Are you subject to a child-support warrant? Yes No I certify that the foregoing responses made by me are true and I am aware that the making of false statements may subject me to contempt of court. ______________________________________________ __________________ Signature Date BLS-43 (R 9/09) On the Road to Excellence www.njmvc.gov New Jersey is an Equal Opportunity Employer American LegalNet, Inc. www.FormsWorkFlow.com Business Licensing Services Bureau P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 # 5014 EMISSION REPAIR FACILITY TECHNICIAN I, the undersigned, certify that the below listed employee(s) meet the repair Technician Certification requirements. NAME SSN ADDRESS LIST CERTIFICATIONS ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________ Licensee’s Name and Title _______________________________ Date On the Road to Excellence www.njmvc.gov New Jersey is an Equal Opportunity Employer BLS-64(R9/09) American LegalNet, Inc. www.FormsWorkFlow.com New Jersey Motor Vehicle Commission Business License Services P.O. Box 170 Trenton, New Jersey 08666-0170 BUSINESS HOURS Name of Business___________________________________ License No. ___________________________ Address_________________________________________________________________________________ Days Open for Business Business Hours Monday From To Tuesday From To Wednesday From To Thursday From To Friday From To Saturday From To Signature of Proprietor, partner or officer_____________________________________________________ Date____________________________ MM BLC-86A (R12/03) American LegalNet, Inc. www.FormsWorkFlow.com