D. A license or operating certificate issued by an appropriate department of the State of New York or the County of
Westchester is required to have been issued before this application may be approved for any of the categories listed in
(A) on the reverse side. License or Operating Certificate issued by: NYS # Westchester#
Permit Issued by: Social Services# Mental Hygiene # Other #
E.
Ownership and Management of Premises:
1. Owner of record:
Name :
Address:
City: State: ZIP CODE
Phone:
2. Manager* or Caretaker*: Name:
Address**
City: State:
ZIP CODE
* Must be resident on premises if seven or more accomodations. ** Must be authorized to accept legal process.
3. Applicant***: Name :
Address:
City: State : ZIP CODE
***Must be person, corporation or organization responsible for operating facility.
APPLICANT MANAGER
4. Citizen of United States?
5. Able to read and write the English Language?
6. Ever convicted of felony or misdemeanor?
7. Previously conducted this type of residence?
8. If answer to (7) was "No", have experience in any other type listed in Section (A)?
9. If answer to (8) was affirmative, what type?
F. ( Notarization )
State of New York }ss.
County of Westchester }
, being duly sworn, deposes and says: that he or she has read the
foregoing application and knows the contents thereof that the same is true to the knowledge of
the deponent, except as to those matters therein stated to be alleged on information and belief,
and as to those matters, he or she believes it to be true. He or she further says that he or she is
authorized by the owner to make this application.
Sworn to before me on this day
of
Signature of Applicant
FORM SRFapptemp11/06
Notary Public
Page Two
SPECIAL RESIDENCE FACILITY SHELTER APPLICATION
Phone:
Phone:
