NHWPrenew

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

PO Box 805

Trenton, New Jersey 08625-0805

(609) 984-7534/984-7563

NEW HOME BUILDER REGISTRATION APPLICATION - RENEWAL APPLICATIONNEW HOME BUILDER REGISTRATION APPLICATION - RENEWAL APPLICATION

NEW HOME BUILDER REGISTRATION APPLICATION - RENEWAL APPLICATION

Instructions

Please read carefully before completing this application.

Application must be typed or completed in ink.

1. A nonrefundable registration fee of $200 must accompany this application. Make check or money

order payable to “STATE OF NEW JERSEY, NEW HOME WARRANTY FUND.” Maker of check must

be the registering business or a principal named in the application.

2. Allow at least 20 working days for the processing of this application.

PAGE 1. NAME OF NEW HOME BUILDING BUSINESS - The name of the business which is

transferring title is the entity which must register and warrant the new home.

LOCATION ADDRESS - must be a street address, post office box is not acceptable.

PAGE 4. Each individual completing a page 2 or 3 must be listed on page 4.

Voluntarily providing your social security number will enable the program to more efficiently conduct

the necessary background checks before issuing a Certificate Of Registration. (NJSA 46:3B-5 and

NJAC 5:3-1.2)

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

PO Box 805

Trenton, New Jersey 08625-0805

NEW HOME BUILDER REGISTRATION - RENEWAL APPLICATIONNEW HOME BUILDER REGISTRATION - RENEWAL APPLICATION

NEW HOME BUILDER REGISTRATION - RENEWAL APPLICATION

IF THIS BUILDING BUSINESS IS NO LONGER ENGAGED IN THE CONSTRUCTION OF NEW HOMES,

CHECK BOX AT RIGHT, SIGN AND RETURN FORM TO THIS OFFICE.

***NOTE******NOTE***

***NOTE*** IF YOU HAVE PROVIDED WARRANTIES TO HOMES WHICH ARE IN THE FIRST TWO (2) YEARS OF

COVERAGE, YOU MUST MAINTAIN A CURRENT REGISTRATION.

NAME OF NEW HOME BUILDING BUSINESS

(1 person)

TYPE OF BUSINESS

(check one)

Sole Proprietorship General Partnership*

Corporation*

Limited Partnership* Joint Venture*

LIMITED LIABILITY COMPANY *

AGENT

(individual, with New Jersey address)

(FOR CORPORATION OR LIMITED LIABILITY CO.)

Name

Street & No.

City

State Zip Code

Business Phone ( )

WARRANTY SECURITY OPTION

(check one)

State Plan

Private Plan (Complete Information Below)

PRIVATE PLAN NAME

PRIVATE PLAN I.D. NO.

LOCATION ADDRESS LOCATION ADDRESS

LOCATION ADDRESS

(where business records are maintained)

Street & No.

City

County

State Zip Code

Business Phone ( )

Fax Number ( )

MAILING ADDRESS

(this is the address where official notifications will be received)

Street & No.

City

State Zip Code

Are there any unsatisfied judgements against this building entity? Yes No

If yes, do the judgements relate to the construction or sale of real estate? Yes No

Description of Judgement

Amount of Judgement Date of Judgement

Is this business currently in bankruptcy or has application been made for bankruptcy protection? Yes No

(must be officer/principal of building business)

AUTHORIZED SIGNATUREAUTHORIZED SIGNATURE

AUTHORIZED SIGNATURE DATE

NAME TITLE

(PRINT OR TYPE)

2/00

(Instructions Attached)(Instructions Attached)

(Instructions Attached)

(must be signed by individual listed in section 2A)

(Print or type)

2/00

STATE OF NEW JERSEYSTATE OF NEW JERSEY

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRSDEPARTMENT OF COMMUNITY AFFAIRS

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

SCHEDULE A - Builder DesigneeSCHEDULE A - Builder Designee

SCHEDULE A - Builder Designee

RENEWAL APPLICATIONRENEWAL APPLICATION

RENEWAL APPLICATION

NAME OF BUSINESSNAME OF BUSINESS

NAME OF BUSINESS

The builder designee must be the name of an

INDIVIDUAL who is a primary partner, principal, officer or director designated as such

in the builder’s application for registration and is the

INDIVIDUAL responsible for participating in the claims process, if necessary.

(SOLE PROPRIETORS MUST ALSO COMPLETE THIS PAGE)

SECTION 2A - BUILDER DESIGNEE SECTION 2A - BUILDER DESIGNEE

SECTION 2A - BUILDER DESIGNEE

(print or type)

Name Business Telephone ( )

Title

Home Address

City State Zip Code

SECTION 2BSECTION 2B

SECTION 2B

If you are or have ever been a builder designee, officer, partner or a holder of a minimum of 10% interest in any other new home

building business, list them below.

ALL CURRENT AS WELL AS INACTIVE BUSINESSES MUST BE LISTED.

(use a separate sheet

if necessary.)

FromFrom

From

ToTo

To

Company NameCompany Name

Company Name

Registration #Registration #

Registration #

PositionPosition

Position

OwnershipOwnership

Ownership

Percent Percent

Percent

Yes No

SECTION 2CSECTION 2C

SECTION 2C

Has the INDIVIDUAL making this disclosure ever been subject to any CRIMINAL, CIVIL OR ADMINISTRATIVE proceeding

involving any finding of CONSUMER FRAUD in this State, the United States, or any other state or foreign country?

YES NO

If yes, please complete the questions below.

NATURE OF PROCEEDINGNATURE OF PROCEEDING

NATURE OF PROCEEDING

JURISDICTIONJURISDICTION

JURISDICTION

DATEDATE

DATE

SECTION 2DSECTION 2D

SECTION 2D

Does the individual making this disclosure have any unsatisfied judgements? Yes No

If yes, do the judgements relate to the construction or sale of real estate? Yes No

Description of Judgement

Amount of Judgement Date of Judgement

I certify that the foregoing statements made by me are true. I am aware that if any statements are willfully false this registration may

be revoked. Failure to disclose may also result in revocation of registration.

SIGNATURESIGNATURE

SIGNATURE

DATEDATE

DATE

NAMENAME

NAME

!

STATE OF NEW JERSEYSTATE OF NEW JERSEY

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRSDEPARTMENT OF COMMUNITY AFFAIRS

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

SCHEDULE B - Officers/PrincipalsSCHEDULE B - Officers/Principals

SCHEDULE B - Officers/Principals

RENEWAL APPLICATIONRENEWAL APPLICATION

RENEWAL APPLICATION

NAME OF BUSINESSNAME OF BUSINESS

NAME OF BUSINESS

TYPE OF APPLICATIONTYPE OF APPLICATION

TYPE OF APPLICATION

A SEPARATE SCHEDULE B (PAGE 3) MUST BE COMPLETED FOR EACH OFFICER, PARTNER AND PRINCIPAL IN THIS

BUSINESS. Also complete a separate schedule B for all individuals who hold a minimum of 10% interest.

**NOTE** EACH

INDIVIDUAL NAMED IN THE CERTIFICATE OF INCORPORATION, PARTNERSHIP/JOINT VENTURE AGREEMENT OR

LIMITED LIABILITY COMPANY MUST COMPLETE A SEPARATE PAGE 3. (This page may be be photocopied if necessary.)

SECTION 3A -OFFICER/PRINCIPAL SECTION 3A -OFFICER/PRINCIPAL

SECTION 3A -OFFICER/PRINCIPAL

(print or type)

Name Business Telephone ( )

Title

Home Address

City State Zip Code

SECTION 3BSECTION 3B

SECTION 3B

If you are or have ever been a builder designee, officer, partner or a holder of a minimum of 10% interest in any other new home

building business, list them below.

ALL CURRENT AS WELL AS INACTIVE BUSINESSES MUST BE LISTED.

(use a separate sheet

if necessary.)

FromFrom

From

ToTo

To

Company NameCompany Name

Company Name

Registration #Registration #

Registration #

PositionPosition

Position

OwnershipOwnership

Ownership

Percent Percent

Percent

Yes No

SECTION 3CSECTION 3C

SECTION 3C

Has the INDIVIDUAL making this disclosure ever been subject to any CRIMINAL, CIVIL OR ADMINISTRATIVE proceeding

involving any finding of CONSUMER FRAUD in this State, the United States, or any other state or foreign country?

YES NO

If yes, please complete the questions below.

NATURE OF PROCEEDINGNATURE OF PROCEEDING

NATURE OF PROCEEDING

JURISDICTIONJURISDICTION

JURISDICTION

DATEDATE

DATE

SECTION 3DSECTION 3D

SECTION 3D

Does the individual making this disclosure have any unsatisfied judgements? Yes No

If yes, do the judgements relate to the construction or sale of real estate? Yes No

Description of Judgement

Amount of Judgement Date of Judgement

I certify that the foregoing statements made by me are true. I am aware that if any statements are willfully false this registration may

be revoked. Failure to disclose may also result in revocation of registration.

SIGNATURESIGNATURE

SIGNATURE

DATEDATE

DATE

NAMENAME

NAME

(Print or type)

(must be signed by individual listed in section 3A)

2/00

!

STATE OF NEW JERSEYSTATE OF NEW JERSEY

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRSDEPARTMENT OF COMMUNITY AFFAIRS

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

SCHEDULE B - Officers/PrincipalsSCHEDULE B - Officers/Principals

SCHEDULE B - Officers/Principals

RENEWAL APPLICATIONRENEWAL APPLICATION

RENEWAL APPLICATION

NAME OF BUSINESSNAME OF BUSINESS

NAME OF BUSINESS

TYPE OF APPLICATIONTYPE OF APPLICATION

TYPE OF APPLICATION

A SEPARATE SCHEDULE B (PAGE 3) MUST BE COMPLETED FOR EACH OFFICER, PARTNER AND PRINCIPAL IN THIS

BUSINESS. Also complete a separate schedule B for all individuals who hold a minimum of 10% interest.

**NOTE** EACH

INDIVIDUAL NAMED IN THE CERTIFICATE OF INCORPORATION, PARTNERSHIP/JOINT VENTURE AGREEMENT OR

LIMITED LIABILITY COMPANY MUST COMPLETE A SEPARATE PAGE 3. (This page may be be photocopied if necessary.)

SECTION 3A -OFFICER/PRINCIPAL SECTION 3A -OFFICER/PRINCIPAL

SECTION 3A -OFFICER/PRINCIPAL

(print or type)

Name Business Telephone ( )

Title

Home Address

City State Zip Code

SECTION 3BSECTION 3B

SECTION 3B

If you are or have ever been a builder designee, officer, partner or a holder of a minimum of 10% interest in any other new home

building business, list them below.

ALL CURRENT AS WELL AS INACTIVE BUSINESSES MUST BE LISTED.

(use a separate sheet

if necessary.)

FromFrom

From

ToTo

To

Company NameCompany Name

Company Name

Registration #Registration #

Registration #

PositionPosition

Position

OwnershipOwnership

Ownership

Percent Percent

Percent

Yes No

SECTION 3CSECTION 3C

SECTION 3C

Has the INDIVIDUAL making this disclosure ever been subject to any CRIMINAL, CIVIL OR ADMINISTRATIVE proceeding

involving any finding of CONSUMER FRAUD in this State, the United States, or any other state or foreign country?

YES NO

If yes, please complete the questions below.

NATURE OF PROCEEDINGNATURE OF PROCEEDING

NATURE OF PROCEEDING

JURISDICTIONJURISDICTION

JURISDICTION

DATEDATE

DATE

SECTION 3DSECTION 3D

SECTION 3D

Does the individual making this disclosure have any unsatisfied judgements? Yes No

If yes, do the judgements relate to the construction or sale of real estate? Yes No

Description of Judgement

Amount of Judgement Date of Judgement

I certify that the foregoing statements made by me are true. I am aware that if any statements are willfully false this registration may

be revoked. Failure to disclose may also result in revocation of registration.

SIGNATURESIGNATURE

SIGNATURE

DATEDATE

DATE

NAMENAME

NAME

(Print or type)

(must be signed by individual listed in section 3A)

2/00

"

2/00

NAME OF BUSINESSNAME OF BUSINESS

NAME OF BUSINESS

SECTION 1 - OFFICERS/PRINCIPALS (SOLE PROPRIETORSHIPS MUST ALSO COMPLETE THIS PAGE)

LIST BELOW THE NAMES, ADDRESSES AND POSITIONS OF EACH OFFICER, PARTNER, AND INDIVIDUAL IN THE BUSINESS.

ALSO LIST THE NAMES AND ADDRESSES FOR ALL INDIVIDUALS WHO HOLD A MINIMUM OF 10% INTEREST IN THIS BUSINESS.

IF SOCIAL SECURITY NUMBERS ARE PROVIDED THEY WILL REMAIN CONFIDENTIAL AND WILL NOT REMAIN IN FILES

REVIEWED OR COPIES BY THE GENERAL PUBLIC. (This page may be photocopied if necessary)

Name: Home Telephone:

Home Address: Social Security No.

City: State: Zip Code:

Name: Home Telephone:

Home Address: Social Security No.

City: State: Zip Code:

Name: Home Telephone:

Home Address: Social Security No.

City: State: Zip Code:

Name: Home Telephone:

Home Address: Social Security No.

City: State: Zip Code:

Name: Home Telephone:

Home Address: Social Security No.

City: State: Zip Code:

STATE OF NEW JERSEYSTATE OF NEW JERSEY

STATE OF NEW JERSEY

DEPARTMENT OF COMMUNITY AFFAIRSDEPARTMENT OF COMMUNITY AFFAIRS

DEPARTMENT OF COMMUNITY AFFAIRS

Division of Codes and Standards

Bureau of Homeowner Protection

New Home Warranty Program

SCHEDULE C - OFFICERS/PRINCIPALSSCHEDULE C - OFFICERS/PRINCIPALS

SCHEDULE C - OFFICERS/PRINCIPALS

RENEWAL APPLICATIONRENEWAL APPLICATION

RENEWAL APPLICATION