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Get NY LIC34 2008

LIC34 Licensing Supplemental Affidavit Application must be typewritten. 1 Convictions If you have been convicted of an offense explain fully in the boxes below. Date of Charge or Offense Name of Court and Location Sentence or Disposition 2 Penalties and Fines If you or the company/business with which you have been associated have outstanding penalties fines or fees owed to the City of New York list them below. Debtor New York City Agency/Authority Amount Owed 3 Statements and Signatures Indicates optional As a condition of being granted a License from the Department of Buildings I hereby comply with all New York City Administrative Code Provisions and Departmental Rule Regulations and Directives regarding how licensees conduct their specific trade. I understand falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. I also understand it is unlawful to give to a city employee or for a city employee to accept any benefit monetary or otherwise either as a gratuity for properly performing the job or in exchange for special consideration* Such action is punishable by imprisonment or fine or both. Last Name First Name Middle Initial Business Name Telephone Address Fax City State Zip Mobile Telephone E-Mail Registration/License Number Name print Notarization State of New York County of Signature Sworn to or affirmed under penalty of perjury day of Date Notary Seal Notary Signature 7/08. Date of Charge or Offense Name of Court and Location Sentence or Disposition 2 Penalties and Fines If you or the company/business with which you have been associated have outstanding penalties fines or fees owed to the City of New York list them below. Debtor New York City Agency/Authority Amount Owed 3 Statements and Signatures Indicates optional As a condition of being granted a License from the Department of Buildings I hereby comply with all New York City Administrative Code Provisions and Departmental Rule Regulations and Directives regarding how licensees conduct their specific trade. Debtor New York City Agency/Authority Amount Owed 3 Statements and Signatures Indicates optional As a condition of being granted a License from the Department of Buildings I hereby comply with all New York City Administrative Code Provisions and Departmental Rule Regulations and Directives regarding how licensees conduct their specific trade. I understand falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. I understand falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. I also understand it is unlawful to give to a city employee or for a city employee to accept any benefit monetary or otherwise either as a gratuity for properly performing the job or in exchange for special consideration* Such action is punishable by imprisonment or fine or both. I also understand it is unlawful to give to a city employee or for a city employee to accept any benefit monetary or otherwise either as a gratuity for properly performing the job or in exchange for special consideration* Such action is punishable by imprisonment or fine or both. Last Name First Name Middle Initial Business Name Telephone Address Fax City State Zip Mobile Telephone E-Mail Registration/License Number Name print Notarization State of New York County of Signature Sworn to or affirmed under penalty of perjury day of Date Notary Seal Notary Signature 7/08. .

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  7. Send immediately towards the receiver.

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