Moral Character Attestation Of Unlicensed Shareholder, Officer, Or Director For A Design Professional Corporation Template printable pdf download

The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of the Professions

Division of Professional Licensing Services

Moral Character Attestation of Unlicensed Shareholder, Officer, or Director for a

Design Professional Corporation

This form must be completed by each unlicensed individual who is a shareholder, officer, or director of an entity that is applying for a

certificate of authority as a Design Professional Corporation. Complete both pages of this form and be sure to sign and date the Attestation.

This form must be submitted with the initial filing to the address at the end of the form.

Name of Entity: ________________________________________________________________________________________________

Do you now hold, or have ever held, a license or certificate to practice any profession in any jurisdiction? (if so, list below and attach

additional sheets if necessary.)

F Yes

F No

Profession _____________________________________ License number _______________ Jurisdiction ________________________

Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any

court?

F Yes

F No

Are criminal charges pending against you in any court?

F Yes

F No

Has any licensing or disciplinary authority refused to issue you a license, or ever revoked, annulled, cancelled, accepted surrender of,

suspended, placed on probation or refused to renew a professional license or certificate held by you now or previously, or ever fined,

censured, reprimanded or otherwise disciplined you?

F Yes

F No

Are charges pending against you in any jurisdiction for any sort of professional misconduct?

F Yes

F No

Has any licensed facility restricted or terminated your professional training, employment or privileges or have you ever voluntarily or

involuntarily resigned or withdrawn from such association to avoid imposition of such measures?

F Yes

F No

Have you ever willfully failed to provide records to any State Licensing authority or to Federal, State or Local law enforcement officials

that are required by Federal, State or Local laws?

F Yes

F No

If yes, please explain: ___________________________________________________________________________________________

_____________________________________________________________________________________________________________

NOTE: If you answer "Yes" to any questions numbered 2-8, submit a letter giving a complete detailed explanation. Include copies of any

court records including a Certificate of Conviction. If there are offenses in multiple courts, please provide the same for each action. If the

court can no longer provide documentation, you must request, from the court, a letter stating why they cannot provide the documents. Minor

traffic violations, charges that were dismissed, and acquittals do not come under this category.

DPC Form 1, Page 1 of 2, 1/12

Moral Character Attestation Of Unlicensed Shareholder, Officer, Or Director For A Design Professional Corporation Template

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