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250 Broadway, 29th Floor New York, NY 10007 212-386-0009 - Phone 646-500-6271 - Fax www.nyc.gov/bsa PHYSICAL CULTURE PRINCIPAL QUESTIONNAIRE FORM Please complete and return to: Board of Standards and Appeals 250 Broadway, 29th Floor New York, NY 10007 TO BE COMPLETED BY EACH PRINCIPAL, OWNER, AND OPERATOR OF PROPOSED PHYSICAL CULTURE ESTABLISHMENTS. IF IT IS NECESSARY TO PROVIDE ADDITIONAL INFORMATION IN RESPONSE TO A QUESTION, COMPLETE ON A SEPARATE SHEET AND INDICATE THE NUMBER OF THE QUESTION BEING ANSWERED. COMPANY NAME:__________________________________________________________________________________________________ AKA/DBA _____________________________________________________________________________ BOARD OF STANDARDS AND APPEALS APPLICATION NO.:____________________________________________________________ PRINCIPAL NAME:__________________________________________________________________________________________________ DATE OF BIRTH:_______________________________ SOCIAL SECURITY NO. __________________________________________ HOME ADDRESS:___________________________________________________________________________________________________ OTHER PRESENT ADDRESS: (Include work address) ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ POSITION HELD:______________________________________________________ DATE STARTED:_________________________ 1. Do you have an equity or partnership interest in the applying firm? YES NO If yes, describe:__________________________________________________________________________________________ Percent of interest held:_________________ Date(s) acquired:__________________________________________________ 2. Name any other physical culture establishment with which you have been connected, other than above: Address Date of Affiliation Position BSA Calendar No. Business Entity Name 3. Have you, or a business entity in which you were a principal, (other than the present submitting entity) been informed that you (it) was YES NO ineligible to do business with any governmental agency? If yes, give details on a separate sheet (include governmental agency, business entity, and date). 4. Have you or any business entity, in which you are or have been a principal (including the present submitting entity) ever been charged with any violation of the zoning resolution, or any variance or special permit grant by the City of New York, or been involved in any compliance or enforcement proceeding involving such alleged violation? 5. Have you ever been convicted of a felony or a misdemeanor? YES YES NO NO If yes, state details:________________________________________________________________________________________ Court of Conviction:___________________________________ State:______________________________________________ www.nyc.gov/bsa American LegalNet, Inc. www.FormsWorkFlow.com 6. Are any criminal charges presently pending against you? YES NO If yes, state details:________________________________________________________________________________________ Date of Charges:________________ Index or Docket #_________________ Court_____________ State:______________ Pending Charges:__________________________________________________________________________________________ 7. To your knowledge, have you or any business entity with which you have been a principal, ever been the subject of an investigation by any governmental agency? YES NO If yes, state name of agency, date and details of Investigation on separate sheet. 8. Have there ever been any arrests on the premises underlying this application for a variance or special permit. YES NO If yes, state details:________________________________________________________________________________________ 9 Are you or any business entity (other than the present submitting entity) in which you are a principal presently involved in an litigation with or against the City of New York or any of its agencies. YES NO If yes, provide a caption of the case, the court, and the index or docket number on a separate sheet. A MATERIAL FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS QUESTIONNAIRE 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 I,__________________________________, being duly sworn, state that I have read and understand all the items contained in the above questionnaire and the following_______ pages of attachments; that I supplied full and complete information and answers to each item therein to the best of my knowledge, information, and belief, and that all information supplied by me is true. I further understand that this questionnaire is submitted as additional inducement to the City of New York to grant the applied for variance or permit and that the City will rely on the information supplied herein. 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