Fillable Physical Culture Principal Questionnaire Form (Page 2 of 2) in pdf

Are any criminal charges presently pending against you?

YES

If yes, state details:________________________________________________________________________________________

Date of Charges:________________ Index or Docket #_________________

Court_____________

State:______________

Pending Charges:__________________________________________________________________________________________

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

If yes, state name of agency, date and details of Investigation on separate sheet.

Have there ever been any arrests on the premises underlying this application for a variance or special permit.

YES

If yes, state details:________________________________________________________________________________________

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

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.

Physical Culture Principal Questionnaire Form Page 2