Employment Agency Self-Certification - Nyc Department Of Consumer Affairs Page 5
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20PART III
This part of the Self-Certification covers New York State and City laws relevant to employment
agencies. Please read each section carefully. Included in each section are checklists. You must check
each requirement that applies to your agency to certify that you understand and will comply with
the requirement.
Important: If you submit an incomplete Self-Certification, your application will be denied or the
Department of Consumer Affairs (DCA) may request additional information.
Section 1: Settlement Agreements/Orders
Check the box or boxes that apply to you.
I have entered into an Agreement, Settlement Agreement, Consent Judgment Order, or Consent Order
(collectively referred to as “settlement agreement”) with DCA.
My agency has entered into an Agreement, Settlement Agreement, Consent Judgment Order, or
Consent Order (collectively referred to as “settlement agreement”) with DCA.
I am a new applicant, and this Section does not apply to me or my agency.
I am a renewing licensee, and this Section does not apply to me or my agency.
If you indicated that you or your agency entered into a settlement agreement with DCA, you must
complete these additional checklists about Contracts and Receipts.
I agreed to use DCA’s model contract, or one that is substantially similar, as my agency’s contract
with job applicants. I have complied with this requirement. Beginning on the date of this Self-
Certification, I will use DCA’s model contract as my agency’s contract with job applicants. The model
contract is available for download at nyc.gov/BusinessToolbox.
I agreed to use DCA’s model receipt, or one that is substantially similar, to give to each job applicant
who pays a fee as confirmation of payment. I have complied with this requirement. Beginning on the date
of this Self-Certification, I will use DCA’s model receipt as my agency’s receipt and give a receipt to
each job applicant who pays a fee as confirmation of payment. The model receipt is available for
download at nyc.gov/BusinessToolbox.
Revised 09/19/14
Page 5 of 20
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