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Physical Culture Establishment Questionnaire Form - New York
| Physical Culture Establishment Questionnaire Form Form. This is a New York form and can be used in Board Of Standards And Appeals City Of New York New York Local County . |
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CITY OF NEW YORK BOARD OF STANDARDS AND APPEALS th 40 Rector Street, 9 Floor New York, New York 100061705 Phone: (212) 7888500 FAX: (212)7888769 PHYSICAL CULTURE ESTABLISHMENT QUESTIONNAIRE FORM Please complete and return to: Board of Standards and Appeals th 40 Rector Street, 9 Floor New York, New York 10006 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
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