Doing Business Data Form - Land Use Actions

en-USA Doing Business Data Form must be completed by any land use applicant subject to the provisions of Local Law 34 of 2007 (see Q&A sheet for more information). en-USPlease either type responses directly into this 037llable form or print answers by hand in black ink. For all submissions, please be sure to 037ll out the certi037cation box on the en-USlast page, and include the completed Data Form as part of the land use application package. en-USSubmission of a complete and accurate form is required at the time en-USof application 037ling and, where applicable, is required for the certi037cation or referral forpublic review of any land use application subject to the provisions of en-USLocal Law 34 of 2007 (see 62 RCNY 247 2-02(a)(1)).en-USThis Data Form requires information to be provided on principal of037cers, owners and senior managers. The name, employer and title of each person identi037ed on the en-USData Form will be included in a public database of people who do business with the City of New York, as will the organizations that own 10% or more of the enitity. No en-USother information reported on this form will be disclosed to the public.en-USPlease return the completed Data Form to the City of037ce that supplied it.en-US Please contact the Doing Business Accountability Project aten-US en-USDoingBusiness@mocs.nyc.goven-US or 212-788-8104 with any questions regarding this Data Form. Thank you for your cooperation.en-USIf you are completing this form by hand, en-USplease print clearly. Applicant is a Non-Pro037t þ en-US Yes þ en-USen-US Noen-USApplicant Type þ en-US Corporation (any type) þ en-US Joint Venture þ en-US LLC þ en-US Partnership (any type) þ en-US Sole Proprietor þ en-USen-US Other (specify) þ en-USAddress en-USCity en-US State þ en-US Zip þ en-USPhone þ en-US E-mail en-USProvide your e-mail address in order to receive notices regarding this form by e-mail. en-USApplicant Informationen-USApplicant EIN/TIN þ en-US Applicant Name þ Filing Status þ (Select One) en-USen-US Applicant has never completed a Doing Business Data Form. Fill out the entire form.en-US þ Change from previous Data Form dated en-US. en-USFill out only those sections that have en-USchanged, and indicate the name of the persons who no longer hold positions with the applicant.en-USen-US No Change from previous Data Form dated en-US. en-USSkip to the bottom of the last page. en-USPrincipal Of037cersen-USPlease 037ll in the required identi037cation information for each of037cer listed below. If the applicant has no such of037cer or its equivalent, please check "This position does not en-USexist." If the applicant is 037ling a Change Form and the person listed is replacing someone who was previously disclosed, please check "This person replaced..." and 037ll in en-USthe name of the person being replaced so his/her name can be removed from the en-USDoing Business Database,en-US and indicate the date that the change became effective.en-USChief Executive Of037cer (CEO) or equivalent of037cer þ en-USen-US This position does not existen-US en-USThe highest ranking of037cer or manager, such as the President, Executive Director, Sole Proprietor or Chairperson of the Board.en-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USen-US This person replaced former CEO en-US on date þ en-USChief Financial Of037cer (CFO) or equivalent of037cer þ en-USen-US This position does not existen-US en-USThe highest ranking 037nancial of037cer, such as the Treasurer, Comptroller, Financial Director or VP for Finance.en-USFirst Name þ en-US MI þ en-US Last þ en-US en-USBirth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USen-US This person replaced former CFO en-US on date þ en-USChief Operating Of037cer (COO) or equivalent of037cer þ en-USen-US This position does not existen-US en-USThe highest ranking operational of037cer, such as the Chief Planning Of037cer, Director of Operations or VP for Operations.en-USFirst Name þ en-US MI þ en-US Last þ en-US en-USBirth Date (mm/dd/yy) þ en-USOen-USf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USen-US This person replaced former COO en-US on date þ en-USNEW:en-US Data Forms submitted now must include theen-US en-USlisting of en-USorganizations,en-US as well as individuals, with 10% en-USor more ownership of the entity. Until such certi037cation en-USof ownership is submitted through a change, new or en-USupdate form, a no change form will not be accepted. 1/2018 þ en-USFor information or assistance, please contact the Doing Business Accountability Project at DoingBusiness@mocs.nyc.gov or 212-788-8104. en-USTo be completed by the City agency prior to distribution Agency en-US Application # þ en-USCheck One þ en-USen-US General en-US(en-USGENen-US) þ en-USen-US Lease Acquisition en-US(en-USLESen-US)en-USDoing Business Data Formen-US en-USLand Use Actions American LegalNet, Inc. www.FormsWorkFlow.com en-USPrincipal Ownersen-USPlease 037ll in the required identi037cation information for all individuals or organizations that, through stock shares, partnership agreements or other means, en-USown or controlen-US en-US10% or more of the applicant.en-US If no individual or organization owners exist, please check the appropriate box to indicate why and skip to the en-USSenior Managersen-US en-USsection. If the applicant is owned by other companies that control 10% or more of the entity, those companies must be listed. If an owner was identi037ed on the previous en-USpage, 037ll in his/her name and write "See above." If the applicant is 037ling a Change Form, list any individuals or organizations that are no longer owners at the bottom of en-USthis section. If more space is needed, attach additional pages labeled "Additional Owners."en-USThere are no owners listed because (select one):en-US The entity is not-for-pro037t þ en-US The entity is an individual þ en-USen-US No individual or organization owns 10% or more of the entityen-USOther (explain) þ en-USIndividual Owners (who own or control 10% or more of the applicant)en-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USOrganization Owners (that own or control 10% or more of the applicant)en-USOrganization Name en-USOrganization Name en-USOrganization Name en-USRemove the following previously-reported Principal Ownersen-USName en-US Removal Date þ en-USName en-US Removal Date þ en-USName en-US Removal Date þ en-USSenior Managersen-USPlease 037ll in the required identi037cation information for all senior managers who oversee land use applications. Senior managers include anyone who, either by title or en-USduties, has substantial discretion and high-leveloversight regarding the administration of such land use applications, not limited to the land use application forwhich this en-USform is being 037led. At least one senior manager must be listed, or the Data Form will be considered incomplete. If a senior manager has been identi037ed on a previous en-USpage, 037ll in his/her name and write "See above." If the applicant is 037ling a Change Form, list individuals who are no longer senior managers at the bottom of this section. en-USIf more space is needed, attach additional pages labeled "Additional Senior Managers."en-USSenior Managersen-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USFirst Name þ en-US MI þ en-US Last þ en-US Birth Date (mm/dd/yy) þ en-USOf037ce Title en-US Employer (if not employed by applicant) en-USHome Address en-USRemove the following previously-reported Senior Mana