Fillable Substance Abuse Attestation (City of New York)

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Substance Abuse Attestation (City of New York)

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build safe|live safe licensingDOB@buildings.nyc.gov
nyc.gov/buildings Rev. 11/19
(Print Name)
Print Name
Signature
Date
LIC Type ______________________________
LIC# _____________________________
I, _____________________________________________, attest that I have passed a
substance abuse test conducted by a recognized laboratory service/physician, I have
passed a physical exam that complies with RCNY 104 and I will continue to comply with
these requirements.
In the event of an accident that involves my actions undertaken in connection with my
license, I understand that the Administrative Code requires that I cooperate with any
investigation and that failure to do so may result in immediate suspension, revocation or
disciplinary action.
_______________________________________
_______________________________________
_______________________________________
Substance Abuse Attestation
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Substance Abuse Attestation (City of New York)

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Completed 7 November 2020

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