Ca-L21 - Home Improvement Salesperson License Application

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Steven Bellone

Frank Nardelli

Suffolk County Executive

Commissioner

SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS

P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600

FAX (631) 853-4825

HOME IMPROVEMENT SALESPERSON LICENSE APPLICATION

YOUR SALES APPLICATION WILL BE RETURNED UNLESS YOU PROVIDE:

“Authorization from the

1. A totally completed application. YOU MUST ATTACH A PASSPORT

PHOTO.

person who holds the home improvement

license”

must be completed and signed by the home improvement

Your

license holder.

Photo

2. A totally completed Affirmation (Page 2). Be certain to answer all questions. Sign and date at the bottom.

3. Applicant Background (Pages 3/4) must be completed and

signed.

If you answer YES to any of the

questions, you must provide a detailed explanation as well as any pertinent

documentation.

A copy of your NYS driver’s license or NYSDMV non-driver’s

identification.

The fee for an identification card is fifty dollars ($50.00) per annum

Applications may be submitted Mon-Fri, 9:00 am-4:00 pm. Licenses are issued by appointment.

Please Print – Answer all questions. Immediate notice should be given of any change of address.

Last Name

First Name

Initial

Business Name

Address

Number and Street

Address

- Number and Street

City

State

Zip

City

State

Zip

Telephone Number (including area code)

Type of Business

___Corporation

___Partnership

Home:

Business:

___Sole Proprietorship ___Other

Cell:

Fax:

Date of Birth

Height

Weight

Social Security Number

Month

Day

Year

Ft.

In.

Lbs.

Email Address

1. Have you ever been licensed by this agency? ___No

Previous Employers (List last three, with most recent first)

___Yes, License # ___________________________

Firm ______________________________________________

Address____________________________________________

2. Are you now an officer or principal in a Home Improvement

Co. actively engaged in business in the County of Suffolk?

Dates ___________________ Telephone ______________

___No ___Yes, Name of Firm(s)

Firm ______________________________________________

_____________________________________________

Address____________________________________________

3. Have you ever been an officer, principal, or employed in a

Dates ___________________ Telephone ______________

Home Improvement Company? ___No ___Yes, Name firm

Firm _______________________________________________

& capacity. ________________________________________

Address_____________________________________________

___________________________________________________

Dates ___________________ Telephone ______________

Have you ever been convicted of a violation of law, other than

From the person who holds the Home Improvement License

a traffic violation? ___No ___Yes If yes, explain:

I hereby authorize ___________________________________

__________________________________________________

to represent ________________________________________

__________________________________________________

as a salesperson

_____________________________

__________________________________________________

Signature

Home Improvement License Number ____________________

Privacy Act Statement: Pursuant to the Federal Privacy Act of 1974, as amended, the disclosure of Social Security numbers for applicants is mandatory and is required

by 42 USCS § 666(a)(I3), New York State General Obligation Law § 3-503, and Suffolk County Law § 563.5 and/or SCC 239, and/or sec 275-3A, and/or SCC 313-18A,

and/or SCC 361-3A and/or SCC 391, and/or SCC 460-5, and/or SCC

483.

Such numbers disclosed on the application are requested for the administration of Title IV-D of

the Social Security Act (Child Support Enforcement Act) and related provisions of State

law.

Such numbers will be used by the Department of Labor, Licensing, &

Consumer Affairs to facilitate application processing and to maintain a uniform system of identifying

applicants.

DECLARATION (To be completed by applicant): I declare under penalties of the Penal Law, that I prepared this Application and that the

statements contained therein are, to the best of my knowledge and belief, true, correct and that I have not knowingly and willfully made a

false statement or given information which I know to be false in connection therewith.

Signed _______________________________________________________ Date _______________________________