Affirmation:
I am authorized to complete and submit this application and all attachments (together, the “Application”). I have
reviewed the entire Application. To the best of my knowledge, this Application is true, correct, and complete. If any
of the information in this Application changes, the applicant must inform the Department of Consumer Affairs of
those changes. I also understand that the applicant must comply with all relevant laws and rules if granted a license
to operate.
I understand that the Department of Consumer Affairs has not yet considered this Application. The applicant will not
operate the business until receipt of an actual license document from the Department of Consumer Affairs or until /
unless the Department of Consumer Affairs has given written permission to operate while this Application is
pending. This affirmation 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.
PENALTY FOR FALSE STATEMENTS: It is against the law to make a statement in this Application 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 1 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 Application. These
punishments may include:
▪ fines or penalties of up to $500 for each false statement
▪ permanent loss (revocation) of your license
By signing below, I understand and agree that I am swearing or affirming that I have told the truth on this
Application.
____________________________________
________________________________
Signature of License Applicant
Title/Position (if any)
____________________________________
________________________________
Print Full Name
Date
Debt Collection Agency Licensing & Renewal Supplement: Page 3 of 3
Updated September 2016
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