Employment Agency Renewal Self-Certification - Nyc Department Of Consumer Affairs
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3EMPLOYMENT AGENCY RENEWAL
SELF-CERTIFICATION
Compliance with Employment Agency Laws
Note: If you place or attempt to place job applicants in theatrical engagements (e.g., actors, singers,
models, directors, writers, musicians), you must complete the “Theatrical Employment Agency
Renewal Self-Certification” instead. This form is available at nyc.gov/BusinessToolbox.
If you have not previously submitted to DCA an Employment Agency Self-Certification or your
agency has undergone a change in ownership, you must complete the full “Employment Agency
Self-Certification” instead.
The owner (e.g., sole proprietor, general partner, director, corporate officer, or shareholder owning 10%
or more of company stock) of your agency must complete this form.
Legal Name of Business:
Business’s Trade or Doing-
Business-As (DBA) Name, if
applicable:
DCA License Number:
Employment Agency Address
(Building Number, Street Name,
Unit, e.g., Floor, Suite):
Name of Owner
(e.g. sole proprietor, general
partner, director, corporate
officer, or shareholder owning
10% or more of company
stock):
3/25/2016
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