Employment Agency Self-Certification - Nyc Department Of Consumer Affairs Page 4
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20Educational Experience:
Name of School
Address
Start/End Dates
Type of Coursework /
Degree / or
Certification
Obtained
Have you previously worked at, owned, operated, or had a financial interest in an employment
agency issued violations, shut down, or padlocked by the New York City Department of Consumer
Affairs (DCA) or by the New York State Department of Labor?
Yes
No
If you answered Yes, please enter requested information below.
Legal Name of Employment Agency:
Employment Agency Address (Building Number,
Street Name, Unit, e.g., Floor, Suite):
DCA License Number:
Relationship to Business:
By signing below, I, the Employment Agency Manager, certify that the statements in PART II are true
and correct.
If you submit this form as an electronically filled-in PDF, you may type your name in the signature field.
_______________________________
___________________________
Signature
Print Name
_______________________________
___________________________
Title
Date
Revised 09/19/14
Page 4 of 20
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Parent category: Legal