Information Pledge:
By checking this box, I certify that all information I have provided is true, complete, and accurate to the best of my knowledge. I affirm that I have not knowingly provided any false or misleading information or omitted any relevant details. I understand that any misrepresentation, falsification, or omission of facts may result in the rejection of my application, disqualification from the program, or removal from participation if already accepted. I consent to the New Jersey Department of Health (NJDOH) and its authorized partners collecting, verifying, and retaining the information I have provided for purposes related to public health or emergency response. This includes verification of licenses, credentials, and background information.