7/08
LIC34: Licensing Supplemental Affidavit
Application must be typewritten.
1 Convictions
Date of
Conviction Charge or Offense Name of Court and Location Sentence or Disposition
If you have been convicted of an offense, explain fully in the boxes below.
2 Penalties and Fines
3 Statements and Signatures (*Indicates optional)
As a condition of being granted a License from the Department of Buildings, I hereby comply with all New York City Administrative Code Provisions and Departmental Rule, Regulations, and
Directives regarding how licensees conduct their specific trade. I understand falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment, or both. I also
understand it is unlawful to give to a city employee, or for a city employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job or in exchange for
special consideration. Such action is punishable by imprisonment or fine or both.
Last Name First Name Middle Initial
Business Name Telephone
Address *Fax
City State Zip *Mobile Telephone
*E-Mail Registration/License Number
Name (print) Notarization
State of New York, County of:
Notary Seal
Signature
Sworn to or affirmed under penalty of perjury
day of 20
Date
Notary Signature
New York City Agency/Authority Amount Owed
If you, or the company/business with which you have been associated, have outstanding penalties, fines or fees owed to the City of New York,
list them below.
Debtor
