Physical Culture Principal Questionnaire Form
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1
2250 Broadway, 29th Floor
New York, NY 10007
212-386-0009 - Phone
646-500-6271 - Fax
PHYSICAL CULTURE PRINCIPAL QUESTIONNAIRE FORM
Please complete and return to:
Board of Standards and Appeals
250 Broadway, 29th Floor
New York, NY 10007
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:__________________________________________________________________________________________________
COMPANY NAME:__________________________________________________________________________________________________
AKA/DBA
AKA/DBA
_____________________________________________________________________________
_____________________________________________________________________________
BOARD OF STANDARDS AND APPEALS APPLICATION NO.:____________________________________________________________
BOARD OF STANDARDS AND APPEALS APPLICATION NO.:____________________________________________________________
PRINCIPAL NAME:__________________________________________________________________________________________________
PRINCIPAL NAME:__________________________________________________________________________________________________
DATE OF BIRTH:_______________________________
DATE OF BIRTH:_______________________________
SOCIAL SECURITY NO. __________________________________________
SOCIAL SECURITY NO. __________________________________________
HOME ADDRESS:___________________________________________________________________________________________________
HOME ADDRESS:___________________________________________________________________________________________________
OTHER PRESENT ADDRESS: (Include work address)
OTHER PRESENT ADDRESS: (Include work address)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
POSITION HELD:______________________________________________________
POSITION HELD:______________________________________________________
DATE STARTED:_________________________
DATE STARTED:_________________________
1.
1.
Do you have an equity or partnership interest in the applying firm?
Do you have an equity or partnership interest in the applying firm?
YES
YES
NO
NO
If yes, describe:__________________________________________________________________________________________
If yes, describe:__________________________________________________________________________________________
Percent of interest held:_________________
Percent of interest held:_________________
Date(s) acquired:__________________________________________________
Date(s) acquired:__________________________________________________
2.
2.
Name any other physical culture establishment with which you have been connected, other than above:
Name any other physical culture establishment with which you have been connected, other than above:
Business Entity Name
Business Entity Name
Address
Address
Date of Affiliation
Date of Affiliation
Position
Position
BSA Calendar No.
BSA Calendar No.
3.
3.
Have you, or a business entity in which you were a principal, (other than the present submitting entity) been informed that you (it) was
Have you, or a business entity in which you were a principal, (other than the present submitting entity) been informed that you (it) was
ineligible to do business with any governmental agency?
ineligible to do business with any governmental agency?
YES
YES
NO
NO
If yes, give details on a separate sheet (include governmental agency, business entity, and date).
If yes, give details on a separate sheet (include governmental agency, business entity, and date).
4.
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 you or any business entity, in which you are or have been a principal (including the present submitting entity) ever been charged
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
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
compliance or enforcement proceeding involving such alleged violation?
compliance or enforcement proceeding involving such alleged violation?
YES
YES
NO
5.
5.
Have you ever been convicted of a felony or a misdemeanor?
Have you ever been convicted of a felony or a misdemeanor?
YES
YES
NO
If yes, state details:________________________________________________________________________________________
If yes, state details:________________________________________________________________________________________
Court of Conviction:___________________________________ State:______________________________________________
Court of Conviction:___________________________________ State:______________________________________________
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