Fillable BASIC LICENSE APPLICATION (City of New York)

Fill Online, Printable, Fillable, Blank BASIC LICENSE APPLICATION (City of New York) Form

Use Fill to complete blank online CITY OF NEW YORK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BASIC LICENSE APPLICATION (City of New York)

On average this form takes 62 minutes to complete

The BASIC LICENSE APPLICATION (City of New York) form is 7 pages long and contains:

  • 1 signature
  • 108 check-boxes
  • 195 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of New York

BROWSE CITY OF NEW YORK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Basic License Application, 02/21/2018
BASIC LICENSE APPLICATION
Please print.
Section 1 – All applicants
What is your Business’s legal structure?
Business/General Partnership Limited Partnership
Corporation Non-Profit
Limited Liability Company S-Corporation
Limited Liability Partnership Sole Proprietorship
If your Business’s legal structure is Sole Proprietorship or if your Business has an individual general partner,
complete Sections 1, 2, and 4.
If your Business’s legal structure is NOT Sole Proprietorship and your Business does not have an individual
general partner, complete Sections 1, 3, and 4.
Business Information
Business Name
(The Business Name that you provide must be exactly as filed with the New York State Secretary of State or County Clerk.)
Doing-Business-As (DBA)/Trade Name
(The DBA/Trade Name that you provide must be exactly as filed with the New York State Secretary of State or County Clerk.)
Premises Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
E-mail
(By providing your e-mail address, you consent to receive communications electronically from the Department of Consumer Affairs
(DCA), and you affirm that the e-mail listed is a reliable form of communication for you.)
Phone 1 (Primary)
( )
Phone 2 (Alternate)
( )
Text Telephone (TTY Phone)
Fax
( )
New York State Sales Tax Identification Number or
Certificate of Authority Application Confirmation Number
(You must complete this section if “Sales Tax Identification
Number” is a requirement on your license application
checklist.)
The Sales Tax Identification Number is the 9, 10, or 11-digit number on your
New York State Department of Taxation and Finance Certificate of
Authority. If you have not received your Certificate of Authority, please enter
the 6-digit confirmation number you received when you submitted the
application for a Certificate of Authority.
-- or

Basic License Application, 02/21/2018
Contact Mailing Information
If you want DCA correspondence addressed and mailed to a contact other than the business name and
address provided on page 1, please complete the information below.
First Name
Middle Name (optional)
Last Name
Title/Position (Check one box only.)
Chairman
Director
Officer
President
Secretary
Treasurer
Trustee
Vice President
Other. Please specify.
Mailing Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
Section 2 - Sole Proprietors and Individual General Partners
Sole proprietors and individual general partners must provide Social Security number or Individual Taxpayer
Identification Number (ITIN) so the City of New York can confirm whether they have outstanding child
support obligations.
Individual #1 (Sole Proprietor or Individual General Partner #1)
Last Name
Suffix
(Jr., Sr., Esq.) (optional)
First Name
Middle Name (optional)
Social Security Number or Individual Taxpayer
Identification Number
--
Date of Birth (YYYY-MM-DD)
--
Home Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
Is Individual #1 under an obligation to pay child support? Yes No
If Yes, Individual #1 must answer ALL questions below.
a. Does the individual owe four or more months of child support
payments?
Yes No
b. Is the individual making child support payments by income execution
or court approved payment plan or by a plan agreed to by the parties?
Yes No
c. Are the individual’s child support obligations the subject of a pending
proceeding?
Yes No
d. Did the individual receive public assistance or Supplemental Security
Income?
Yes No
Basic License Application, 02/21/2018
Individual #2 (Individual General Partner #2)
If there are more than two individual general partners, please attach additional sheets.
Last Name
Suffix
(Jr., Sr., Esq.) (optional)
First Name
Middle Name (optional)
Social Security Number or Individual Taxpayer
Identification Number
--
Date of Birth (YYYY-MM-DD)
--
Home Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
Is Individual #2 under an obligation to pay child support? Yes No
If Yes, Individual #2 must answer ALL questions below.
a. Does the individual owe four or more months of child support
payments?
Yes No
b. Is the individual making child support payments by income execution
or court approved payment plan or by a plan agreed to by the parties?
Yes No
c. Are the individual’s child support obligations the subject of a pending
proceeding?
Yes No
d. Did the individual receive public assistance or Supplemental Security
Income?
Yes No
PERMISSION
If applicable, Individual #1 can answer on behalf of all Individual General Partners. Under the NYC Charter
and Administrative Code, the City requests SSN or ITIN to maintain and update City databases, to carry out
the powers and duties of the Department, and for other purposes necessary to promote the general welfare.
Do individuals give the City of New York permission to use SSN or ITIN for the purposes described above?
Yes No
Section 3 – Business General Partners, Corporate Officers, Shareholders, and
Members
You must provide information on all business general partners and all corporate officers and each
shareholder owning 10% or more of the business applying for a license. Note: Limited Liability Companies
must provide information on all members. Non-Profits must provide information on all officers and all Board
of Directors members. Attach additional sheets if necessary.
Important: If the partner or shareholder is a business (rather than an individual), DCA will verify active status
prior to license issuance. Corporations, Limited Partnerships, Limited Liability Companies, or Limited Liability
Partnerships must register and remain active with the New York State Department of State.
Basic License Application, 02/21/2018
Business General Partners, Corporate Officers, Shareholders, and Members
Individual #1
Last Name
Suffix
( Jr., Sr., Esq.) (optional)
First Name
Middle Name
(optional)
Title/Position (Check one box only.)
Chairman
Director
Officer
President
Secretary
Treasurer
Trustee
Vice President
Other
Social Security Number or
Individual Taxpayer Identification Number
--
% of Ownership
Home Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
Individual #2
Last Name
Suffix
( Jr., Sr., Esq.) (optional)
First Name
Middle Name
(optional)
Title/Position (Check one box only.)
Chairman
Director
Officer
President
Secretary
Treasurer
Trustee
Vice President
Other
Social Security Number or
Individual Taxpayer Identification Number
--
% of Ownership
Home Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Country/Region
Business #1
Business Name
Employer Identification Number (EIN)
-
% of Ownership
Mailing Address (Building Number, Street Name, Apartment/ Suite/Other)
City
State
ZIP Code
Country/Region
Borough:
Bronx Queens
Brooklyn Staten Island
Manhattan Outside of NYC
Basic License Application, 02/21/2018
Business #2
Business Name
Employer Identification Number (EIN)
-
% of Ownership
Mailing Address (Building Number, Street Name, Apartment/ Suite/Other)
City
State
ZIP Code
Country/Region
Borough:
Bronx Queens
Brooklyn Staten Island
Manhattan Outside of NYC
Section 4: Applicant Background Questions – All applicants
Please answer Background Questions on behalf of all individuals named on the application. “Individual”
refers to sole proprietor; individual general partner; corporate officer; shareholder owning 10% or more of the
business; member; officer; Board of Directors member. Attach additional sheets if necessary.
Some background questions inquire about criminal and/or civil charges. A conviction does not, by
itself, mean you will not get a license. Factors such as the nature and seriousness of the offense, the
amount of time that has passed since the conviction, and your age at the time of the conviction will
be considered. However, your license may be denied if you fail to disclose a conviction in response
to the questions.
Descriptions for questions relating to charges should include date of conviction, nature of the
incident, persons involved, and the outcome. Please include convictions for which you might have
been imprisoned or fined even if, in fact, you only had to perform community service or were put on
probation. You may omit parking violations and offenses that resulted in a finding of juvenile
delinquency, youthful offender, wayward minor, or person in need of supervision.
1. Has individual ever been licensed by the New York City
Department of Consumer Affairs (DCA)?
Yes No
If YES, provide the following information.
DCA License Number:
Business/Individual Name:
2. Has individual ever been principal (officer/shareholder/partner/
member) of a DCA-licensed business?
Yes No
If YES, provide the following information.
DCA License Number:
Business/Individual Name:
3. Has individual had ANY government-issued license/permit
denied, suspended, or revoked?
Yes No
If YES, provide the following information:
License/Permit Type:
Government License/Permit Number:
Business/Individual Name:
Basic License Application, 02/21/2018
4. Are there any pending charges against individual?
Yes No
If YES, provide the following information:
Type:
Civil (Court or Government Agency)
Criminal
Please explain.
5. Has individual ever pled guilty or been convicted of ANY crime
or offense?
Yes No
If YES, please explain.
6. Is there any court judgment against individual or individual’s
business?
Yes No
If YES, please explain and state if any judgment has not been paid in full for 30 days or more.
7. Does individual prefer that business inspections be in a
language other than English?
Yes No
If Yes, select one.
Arabic
French
Hindi
Polish
Vietnamese
Bengali
French-Creole
Italian
Russian
Other. Please
specify:
_____________
Cantonese
Haitian Creole
Korean
Spanish
Farsi
Hebrew
Mandarin
Urdu
If you are applying for a Tobacco Retail Dealer, Electronic Cigarette Retail Dealer,
Home Improvement Contractor, Pedicab Business, Special Sale, or Tow Truck Company
license, please answer question #8.
8. Is individual related by blood or marriage to a DCA licensee or
principal (officer/shareholder/partner/member) of a DCA-
licensed business?
Yes No
If YES, provide the following information:
Relationship to Applicant:
Relative First Name:
Relative Middle Name:
Relative Last Name:
Relative Suffix:
DCA License Number:
Business/Individual Name:
Basic License Application, 02/21/2018
PREPARER’S STATEMENT – Please check the box if the statement applies to you.
I am not the license applicant. I am an authorized representative for the license applicant, and I will
submit a Granting Authority to Act Affirmation completed by the license applicant.
Note: The applicant must sign all required documents.
AFFIRMATION – Please read and sign below.
I am authorized to complete and submit this application and all attachments (together, the "Application"). I
have reviewed the entire Application. To the best of my knowledge, this Application is true, correct, and
complete.
If any of the information in this Application changes, the applicant must inform the Department of Consumer
Affairs of those changes. I also understand that the applicant must comply with all relevant laws and rules if
granted a license to operate.
I understand that the Department of Consumer Affairs has not yet considered this Application. The applicant
will not operate the business until receipt of an actual license document from the Department of Consumer
Affairs or until / unless the Department of Consumer Affairs has given written permission to operate while this
Application is pending. This affirmation shall be deemed executed in the City and State of New York and
shall be governed by and construed in accordance with the laws of the State of New York (notwithstanding
New York choice of law or conflict of law principles) and the laws of the United States.
I affirm that these statements are true and correct.
PENALTY FOR FALSE STATEMENTS: It is against the law to make a statement in this Application that you
know is false. If you make a statement that you know is false, you may be punished.
Under Sections 210.45 and 175.30 of the New York Penal Law, you may be:
▪ fined up to $1000 and / or
▪ sent to jail for up to one year
Under Section 175.35 of the New York Penal Law, you may be punished if you:
▪ make a statement that you know is false and / or
▪ make the statement because you intend to mislead the Department of Consumer Affairs
Under Section 175.35 of the New York Penal Law, you may be:
▪ fined up to $5000 or
▪ fined an amount that is twice the amount of money you received by making the false statement and /
or
▪ sent to jail for up to 4 years
The Department of Consumer Affairs may also punish you for making a false statement on this Application.
These punishments may include:
▪ fines or penalties of up to $500 for each false statement
▪ permanent loss (revocation) of your license
By signing below, I understand and agree that:
▪ I am swearing or affirming that I have told the truth on this Application.
____________________________________ ________________________________
Signature of License Applicant Title/Position (if any)
____________________________________ ________________________________
Print Full Name Date
If you are not registered to vote, would you like to register here today? YES NO
Whether you apply to register to vote or not, it will not affect the assistance DCA will provide to you. If you
wish, we will help you in filling out the voter registration application.
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BASIC LICENSE APPLICATION (City of New York)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document