Physical Culture Establishment Questionnaire Form

250 Broadway, 29th Floor New York, NY 10007 212-386-0009 - Phone 646-500-6271 - Fax www.nyc.gov/bsa PHYSICAL CULTURE ESTABLISHMENT QUESTIONNAIRE FORM Please complete and return to: Board of Standards and Appeals 250 Broadway, 29th Floor New York, NY 10007 COMPANY NAME:_______________________________________ AKA/DBA __________________ ADDRESS:_______________________________________________ APPLICATION NO._______________________________________ ADDRESS OF PROPOSED PHYSICAL CULTURE ESTABLISHMENT:____________________________________________________________ LIST ALL THE PRINCIPALS INVOLVED Include owners, partners, directors, operators, and program managers/directors of this specific facility. If necessary, use additional sheets to list all principals. EACH OF THE INDIVIDUALS LISTED HERE MUST COMPLETE A PRINCIPAL QUESTIONNAIRE FORM. PRINCIPALS 1) NAME: HOME ADDRESS: 2) NAME: HOME ADDRESS: 3) NAME: HOME ADDRESS: 4) NAME: HOME ADDRESS: 5) NAME: HOME ADDRESS: 6) NAME: HOME ADDRESS: 7) NAME: HOME ADDRESS: 8) NAME: HOME ADDRESS: DOB / SS# /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ / /_____ __________________________ POSITION HELD: ___________________________ IT IS MY UNDERSTANDING THAT THIS QUESTIONNAIRE WILL BECOME PART OF THE CASE FILE FOR THE APPLICATION AT THE BOARD OF STANDARDS AND APPEALS. SIGNATURE: NAME: (Please type or print) DATE:_________________________________________________ TITLE:_________________________________________________ Subscribed and sworn to before me this___________________________ day of ________________________, 20______. A material false statement willfully or fraudulently made in connection with this application and the accompanying principal questionnaire(s) may result in disqualification for approval of a variance or a special permit, and in addition may subject the person making the false statement to criminal charges. www.nyc.gov/bsa American LegalNet, Inc. www.FormsWorkFlow.com