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STREET PO BOX
COUNTY PHONE ( )
GRADE & PERMIT FEES – PLEASE SEE REVERSE SIDE FOR ADDITIONAL INFORMATION Â
I CERTIFY THAT I AM FAMILIAR WITH AND WILL COMPLY WITH THE NEW JERSEY EXPLOSIVES RULES AND REGULATIONS.
APPLICANT’S SIGNATURE
Once the testing fee is received along with all required documentation, an examination will be
scheduled. If for some reason the applicant is unable to attend, they must call the office before the
test date.
An examiner checks the examination. The applicant will be notified by mail if he/she has passed or
failed the examination. Once the applicant has received his/her notification the testing fee will be
applied to the cost of the permit and the remaining fee shall be submitted to this office for the
processing of the permit.
PERMIT (PROCEDURES)
On receipt of the final payment, the permit will be processed and issued.
I am aware of the Privacy Act of 1974 and I know that information may not be released without my
authorization with the following exceptions:
Each applicant is requested to voluntarily provide his or her social security number in his or her
permit application to assist the Commissioner in the enforcement of the provisions of N.J.S.A.
21:1A-128 et seq.
Each social security number will be used as an identifier in the Department of Labor and Workforce
Development’s (LWD) computerized recordkeeping system to aid in the processing of permit
applications.
Each social security number collected shall remain confidential to the LWD and will not appear on
the actual permit.
I authorize the
(Local Police Department Name)
Police Department to release information regarding previous contacts with me to the Office of
Safety Compliance of the New Jersey Department of Labor and Workforce Development.
If requested, I authorize that this information may be kept on file at the Office of Safety Compliance
of the New Jersey Department of Labor and Workforce Development.
CURRENT ADDRESS:
WITNESS: DATE:
NOTARIZED:
STATE OF NEW JERSEY
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
OFFICE OF PUBLIC SAFETY COMPLIANCE
PO BOX 386
TRENTON, N.J. 08625-0386 F.P.C.
(609) 292-2096
APPLICANT
LAST FIRST MIDDLE
APPLICANT FOR
OCCUPATION SEX RACE
ADDRESS AGE DATE OF BIRTH
HEIGHT WEIGHT BUILD COMPL. HAIR
EYES GLASSES CITIZEN MARITAL STATUS N.P.D. NO.
NAME NEAREST RELATIVE ADDRESS
PRINTS
DATE
TAKEN BY
CLASS TESTED
BY BY SIGNATURE
THUMBS
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PLEASE NOTE: The Fingerprint Card needs to be printed out on ledger or index
paper. If you do not have or can not find ledger or index paper at your local
stationary store, please contact us at (609) 292-2096 and we will mail you the
required Fingerprint Cards.