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Request For Authorization To Use A General Vendor Helper - Nyc Department Of Consumer Affairs Page 2

3. My disability is (check one box):

 Permanent

 Temporary

If your disability is temporary, DCA may require you to submit supplemental medical reports or

certifications to verify the continued existence of your disability.

Important: You must be physically present in order for your helpers to operate your general vending

business. If you will be temporarily absent from your vending display, you must cover the vending display

so that customers know that your display is closed for business. You may receive a violation for

unlicensed activity if a helper is at your uncovered vending display while you are not at the display.

I understand that DCA has not yet considered this request. I will not use helpers until I receive

authorization from DCA. This certification shall be deemed executed in the City and State of New York

and shall be governed by and construed in accordance with the laws of the State of New York

(notwithstanding New York choice of law or conflict of law principles) and the laws of the United States.

I understand that falsification of any statement made herein is an offense punishable by a fine or

imprisonment or both, and may result in the denial of my request or, if granted, revocation of DCA’s

authorization to use helpers. By signing below, I certify that the statements above are true and correct.

__________________________________________________

Signature

Print Name

__________________________________________________

Date

09/22/2016

Request For Authorization To Use A General Vendor Helper - Nyc Department Of Consumer Affairs Page 2