Employment Agency Self-Certification - Nyc Department Of Consumer Affairs
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20EMPLOYMENT AGENCY SELF-CERTIFICATION
Compliance with Employment Agency Laws
This Self-Certification includes four parts:
PART I (general information)
PART II (information about Employment Agency Manager)
PART III (relevant laws and rules and checklists)
PART IV (signature and penalty for false statements)
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 Self-
Certification” instead. This form is available at nyc.gov/BusinessToolbox.
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.
If the owner is not also the Employment Agency Manager, then the Employment Agency Manager must
complete and certify PART II.
PART I
Legal Name of Business:
DCA License Number,
if applicable:
Applicants for a new license do
not need to complete this field.
Business’s Trade or Doing-
Business-As (DBA) Name,
if applicable:
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)
Revised 09/19/14
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