Employment Agency Self-Certification - Nyc Department Of Consumer Affairs Page 19
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20PART IV
Certification:
I am authorized to complete and submit this Self-Certification. I have reviewed the entire Self-
Certification. To the best of my knowledge, this Self-Certification is true, correct, and complete.
If any of the information in this Self-Certification changes, the employment agency must inform the
Department of Consumer Affairs of those changes in writing.
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.
FAILURE TO RETURN OR FULLY COMPLETE THIS SELF-CERTIFICATION:
If you do not return or fully complete this Self-Certification, the Department of Consumer Affairs may
deny your license.
PENALTY FOR FALSE STATEMENTS:
It is against the law to make a statement in this Self-Certification that you know is false. If you make a
statement that you know is false, you may be punished.
Under Sections 210.45 and 175.30 of the New York Penal Law, you may be:
▪
fined up to $1000 and / or
▪
sent to jail for up to one year
Under Section 175.35 of the New York Penal Law, you may be punished if you:
▪
make a statement that you know is false and / or
▪
make the statement because you intend to mislead the Department of Consumer Affairs
Under Section 175.35 of the New York Penal Law, you may be:
▪
fined up to $5000 or
▪
fined an amount that is twice the amount of money you received by making the false statement
and / or
▪
sent to jail for up to 4 years
The Department of Consumer Affairs may also punish you for making a false statement on this Self-
Certification. These punishments may include:
▪
fines or penalties of up to $500 for each false statement
▪
permanent loss (revocation) of your license
Revised 09/19/14
Page 19 of 20
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