Dhcr Application Registration Page 3

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Security Manager 1 Information:
(Last Name)
(First Name)
(Email Address)
Is this person authorized to electronically certify and submit applications on behalf of the applicant?
Yes
No
Security Manager 2 Information:
(Last Name)
(First Name)
(Email Address)
Is this person authorized to electronically certify and submit applications on behalf of the applicant?
Yes
No
Applicant Certification
I certify that I am authorized to file this form with the New York State Division of Housing and Community Renewal
(DHCR) on behalf of the corporation/municipality/firm/person/association/partnership, and to execute all necessary
documents.
I certify that all of the data contained on this Form is true, complete and correct to the best of my knowledge and belief. I
will report any changes or additions to the information provided in this Form, and will furnish such further documentation or
information as maybe requested by DHCR.
I further certify that I am authorized to designate the person named in Section G of this Form as the Applicant's Security
Manager for the CD Online Applications System, and that it is my responsibility to notify DHCR immediately if this person
leaves the Applicant's employ.
(Last Name)
(First Name)
(Email Address)
(Title)
(Signature)
Date:
/
/
Mail Completed Forms to:
NYS DHCR
MSR Unit, Room 603S
Hampton Plaza 38-40 State Street
Albany, NY 12207
Applicant Registration
Rev 11-08

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