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Physical Culture Principal Questionnaire Form. This is a New York form and can be use in New York Local County.
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Tags: Physical Culture Principal Questionnaire Form, New York Local County, New York
CITY OF NEW YORK
BOARD OF STANDARDS AND APPEALS
40 Rector Street, 9th Floor
New York, New York 10006-1705
Phone: (212) 788-8500 FAX: (212)788-8769
PHYSICAL CULTURE PRINCIPAL QUESTIONNAIRE FORM
Please complete and return to:
Board of Standards and Appeals
40 Rector Street, 9th Floor
New York, New York 10006
TO BE COMPLETED BY EACH PRINCIPAL, OWNER, AND OPERATOR OF PROPOSED PHYSICAL CULTURE ESTABLISHMENTS.
IF IT IS NECESSARY TO PROVIDE ADDITIONAL INFORMATION IN RESPONSE TO A QUESTION, COMPLETE ON A SEPARATE
SHEET AND INDICATE THE NUMBER OF THE QUESTION BEING ANSWERED.
COMPANY NAME:__________________________________________________________________________________________________
AKA/DBA
_____________________________________________________________________________
_____________________________________________________________________________
BOARD OF STANDARDS AND APPEALS APPLICATION NO.:____________________________________________________________
PRINCIPAL NAME:__________________________________________________________________________________________________
DATE OF BIRTH:_______________________________
SOCIAL SECURITY NO. __________________________________________
HOME ADDRESS:___________________________________________________________________________________________________
OTHER PRESENT ADDRESS: (Include work address)
(Include
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
POSITION HELD:______________________________________________________
DATE STARTED:_________________________
-----------------------------------------------------------------------------------------------------------
1.
Do you have an equity or partnership interest in the applying firm?
firm?
YES
NO
If yes, describe:__________________________________________________________________________________________
Percent of interest held:_________________
2.
Name any other physical culture establishment with which you have been connected, other than above:
Name
establishment with
Business Entity Name
3.
Date(s) acquired:__________________________________________________
Address
Date of Affiliation
Position
BSA Calendar No.
Have
Have you, or a business entity in which you were a principal, (other than the present submitting entity) been informed that you (it) was
business
submitting
informed
ineligible to do business with any governmental agency?
governme
YES
NO
If yes, give details on a separate sheet (include governmental agency, business entity, and date).
(include governme
4.
Have you or any business entity, in which you are or have been a principal (including the present submitting entity) ever been charged
Have
any busines
which
submitting
been
with any violation of the zoning resolution, or any variance or special permit grant by the City of New York, or been involved in any
permit
compliance or enforcement proceeding involving such alleged violation?
compliance enforcement
5.
Have you ever been convicted of a felony or a misdemeanor?
misdemeanor?
YES
YES
NO
NO
If yes, state details:________________________________________________________________________________________
Court of Conviction:___________________________________ State:______________________________________________
Conviction:___________________________________ State:______________________________________________
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6.
Are any criminal charges presently pending against you?
YES
NO
If yes, state details:________________________________________________________________________________________
Date of Charges:________________
Index or Docket #_________________
Court_____________
State:______________
Pending Charges:__________________________________________________________________________________________
7.
To your knowledge, have you or any business entity with which you have been a principal, ever been the subject of an investigation
by any governmental agency?
YES
NO
If yes, state name of agency, date and details of Investigation on separate sheet.
8.
Have there ever been any arrests on the premises underlying this application for a variance or special permit.
YES
NO
If yes, state details:________________________________________________________________________________________
9
Are you or any business entity (other than the present submitting entity) in which you are a principal presently involved in an
litigation with or against the City of New York or any of its agencies.
YES
NO
If yes, provide a caption of the case, the court, and the index or docket number on a separate sheet.
A MATERIAL FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN
CONNECTION WITH THIS QUESTIONNAIRE MAY RESULT IN DISQUALIFICATION FOR
APPROVAL OF A VARIANCE OR A SPECIAL PERMIT, AND IN ADDITION MAY SUBJECT
THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES
I,__________________________________, being duly sworn, state that I have read and understand all the items contained in
the above questionnaire and the following_______ pages of attachments; that I supplied full and complete information and
answers to each item therein to the best of my knowledge, information, and belief, and that all information supplied by me is
true. I further understand that this questionnaire is submitted as additional inducement to the City of New York to grant the
applied for variance or permit and that the City will rely on the information supplied herein.
IT IS MY UNDERSTANDING THAT THIS QUESTIONNAIRE WILL BECOME PART OF THE CASE FILE FOR THE APPLICATION
AT THE BOARD OF STANDARDS AND APPEALS.
SIGNATURE:
DATE:________________________________
NAME:
TITLE:________________________________
(Please type or print)
Subscribed and sworn to before me this___________________________ day of ________________________, 20______.
A material false statement willfully or fraudulently made in connection with this application and the accompanying principal
questionnaire(s) may result in disqualification for approval of a variance or a special permit, and in addition may subject the person
making the false statement to criminal charges.
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