Theatrical Employment Agency Renewal Self-Certification - Nyc Department Of Consumer Affairs Page 3

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5. I am authorized to complete and submit this Theatrical Employment Agency Renewal Self-
Certification.
6. If any of the information in this Theatrical Employment Agency Renewal Self-Certification
changes, the employment agency will inform DCA of those changes in writing.
FAILURE TO RETURN OR FULLY COMPLETE SELF-CERTIFICATION:
If you do not return or fully complete this Theatrical Employment Agency Renewal Self-Certification or a
full Theatrical Employment Agency Self-Certification (if you did not submit one previously or your
agency had a change in ownership), DCA may deny your license.
PENALTY FOR FALSE STATEMENTS:
It is against the law to make a statement in this Theatrical Employment Agency Renewal Self-
Certification that you know is false. If you make a statement that you know is false, you may be punished
under New York State or City law.
By signing below, I certify that the statements in this Theatrical Employment Agency Renewal Self-
Certification are true, correct, and complete.
If you submit this form as an electronically filled-in PDF, you may type your name in the signature field.
_______________________________
___________________________
Signature
Print Name
_______________________________
___________________________
Position/Title
Date
Please submit the signed original to DCA and make a copy for your records.
All laws and rules of the City of New York, including the New York City Consumer Protection Law and
Rules, are accessible via nyc.gov/consumers. For convenience, sections of relevant New York State Law
and/or New York City Law and Rules are also accessible at nyc.gov/BusinessToolbox.
3/25/2016
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