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Certification Of Licensed Health Care Professional - Nyc Department Of Consumer Affairs

CERTIFICATION OF LICENSED HEALTH

42 Broadway

New York, NY 10004

CARE PROFESSIONAL

Dial 311

(212-NEW-YORK)

The Licensed Health Care Professional must complete this form to

confirm a disability for the General Vendor Licensee requesting

nyc.gov/dca

authorization to use a helper. See the back for information about Section

2-318 of Title 6 of the Rules of the City of New York.

Applicant

Name:

License

Number

(if applicable):

Licensed

Name:

Health Care

___________________________________________

Professional:

Type of Practice:

__________________________________

License No.: _______________________

Phone: (_____) _____ - _______________

Business Address:

______________________________________________

I certify the following:

1. I am licensed as a _____________________________________.

2. I examined the Applicant and found that the Applicant has a disability

that impairs the Applicant’s ability to operate a general vending

business.

3. The Applicant’s disability is (choose one):

 Permanent

 Temporary

If the Applicant’s disability is temporary, provide an estimate of its

duration:

__________________________________________________

Updated 09/22/2016

Certification Of Licensed Health Care Professional - Nyc Department Of Consumer Affairs