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New York City
Department of Buildings
Candidate For License
Background Investigation
Questionnaire
Name:
SS #: — —
License Type:
Date Filed:
1 Rev. 9/08
APPLICANT INITIALS: ________
IMPORTANT: READ THIS SECTION FIRST
• Candidates who have passed the license exam in one of the trades listed below are required to submit this background
investigation questionnaire and all required documents within 60 days of passing the exam to the Buildings
Special Investigations Unit (BSIU). After you have all of the required documents, call 212-825-3330 to schedule an
appointment with an investigator in order to review the documents and initiate your background investigation.
Candidates without an appointment will not be seen. (Although there is no license exam for Contract Elevator Inspector
candidates, the above documents are still required.)
Site Safety Manager
Private Agency Elevator Director/Inspector
Contract Elevator Inspector (CEI)
• Site Safety Coordinator and Hoist Machine Operator Class C candidates should submit this form to the Licensing Unit
upon application.
GENERAL INSTRUCTIONS
CAREFULLY READ ALL INSTRUCTIONS AND ANSWER ALL QUESTIONS. YOUR FAILURE TO
FOLLOW THESE INSTRUCTIONS OR PROPERLY ANSWER ANY QUESTION MAY RESULT IN YOUR
APPLICATION BEING RETURNED FOR ADDITIONAL INFORMATION AND/OR THE DENIAL OF YOUR
LICENSE APPLICATION.
Do not omit any pertinent information. If you are unsure or do not know if you should disclose certain
information, act cautiously and include the information in the questionnaire. Falsification of any
portion of this questionnaire by omitting pertinent information, responding in a misleading manner or
supplying inaccurate or incomplete information, may result in your disqualification.
• Application must be TYPED.
• If additional space is necessary, staple a separate 8 1/2 x 11 sheet of paper to the back of the application.
(Include your name and social security number on each additional sheet)
• If you cross out or change any responses, place your initials next to the corrections.
• Initial the bottom of each page where designated.
• Answer every question or indicate “N/A” (not applicable) when a question does not apply to you.
• Use the “comments” section to elaborate on any question. Please note the question you are referring to.
• You must include a photocopy of your Driver License or Passport and your social security card in your
application packet.
• If an exam is required to apply, you must submit a copy of your passing exam report (does not apply to Site
Safety Coordinator or HMO).
• If a training course is required to apply, you must submit a copy of your certificate of completion (does not ap-
ply to Elevator Director/Inspector).
• For each job you intend to use as qualifying experience for the license, you must obtain a Social
Security History of Earnings statement and notarized letters from your immediate supervisor(s)
for all of your relevant experience. The letters must include your dates of employment, titles
held, daily duties, specific addresses and timeframes for working with major buildings. Major
buildings experience does not apply for Elevator Director/Inspector/CEI. HMO candidates must
include information on types of machinery operated.
Site Safety Managers/Elevator Site Safety Coordinator/HMO-C
If you have any questions you may contact: If you have any questions you may contact:
The New York City Department of Buildings The New York City Department of Buildings
Buildings Special Investigations Unit (BSIU) Licensing Unit
83 Maiden Lane, 4th Floor 280 Broadway, 6th Floor
New York, NY 10038 New York, NY 10007
(212) 825-3330 (212) 566-4100
Failure to submit supporting documentation may result in
your background investigation being delayed or denied!
2 Rev. 9/08
APPLICANT INITIALS: __________
I. Personal Information
Position, Trade License, or Certification applicant is applying for: ELEVATOR DIRECTOR
ELEVATOR INSPECTOR
SITE SAFETY MANAGER
SITE SAFETY COORDINATOR
Last Name CEI
HMO—C (CHERRYPICKER)
First Name Middle Name
— — MM — DD — YYYY
Social Security Number
Date of Birth
Current Address Apt #
City or Town State Zip Code
Home Phone Number Work Phone Number
Cell Phone Number Pager Number
LIST BELOW ALL OTHER NAME(S) YOU ARE KNOWN BY:
(This includes maiden names. If additional space is needed please use comment section on page 17.)
Last Name First Name Middle Name
LIST ANY OTHER SOCIAL SECURITY NUMBER(S) YOU HAVE USED:
— —
Social Security Number
3 Rev. 9/08
APPLICANT INITIALS: _________
II. MISCELLANEOUS QUESTIONS
For questions 1-4, if you answer “YES” you must provide complete details specifying date,
business or agency, reason, disposition, etc. in the Comments Section on page 17.
YES / NO
1. Were you ever employed with a City, State, or Federal Agency?
2. Were you ever barred or disqualified from a City, State or Federal job?
3. Were your ever disciplined (e.g. suspended, demoted, reprimanded, fined,
fired, terminated, discharged, etc.) in any position by either a public or private
employer?
4. Have you ever resigned from a job to avoid termination or disciplinary action,
or while a disciplinary action was pending?
III. RESIDENCE
Starting with your present address and working back, list the full address of every place you have resided
for more than a three month period. List only your residences over the past ten years or since you left high
school, whichever is less.
FROM TO Street Address and City State and Zip Code
(MM/DD/YY) (MM/DD/YY)
PRESENT
APPLICANT INITIALS: _________ 4 Rev. 9/08
IV. CRIMINAL HISTORY
List any and ALL of your convictions and pending charges below. You MUST list every conviction or pending
charge (s). If you do not recall all of your convictions, then you MUST indicate this below. (Do NOT include traffic
moving violations in this section). You are not automatically disqualified because of a criminal conviction.
1) Have you ever been convicted* of an offense anywhere (an offense is defined as a Violation,
Misdemeanor or Felony). If you are not sure of the type of offense, answer “yes” anyway. You do not have to
disclose any material sealed, expunged, or set aside under Federal or State Law or Juvenile Delinquent or
Youthful Offender Adjudication. YES NO
* A conviction means that you appeared before a court and/or a judge (either administrative or criminal) and either pled guilty,
were determined guilty by a jury or judge, or paid a fine. You do not have to get arrested to be guilty of an offense. If you received a
summons or ticket for anything other than a parking ticket on your car or a moving violation such as speeding, you MUST include
it in this section. You MUST list any convictions for Driving Under the Influence (DUI), Driving While Intoxicated (DWI), or
driving without a license. Please list all convictions below. If additional space is needed please use page 17.
A) Convictions
List ALL Convictions Below:
CONVICTION OFFENSE NAME and LOCATION SENTENCE and DATE
DATE (INCLUDE DETAILS) OF COURT of SENTENCE
YES NO
B) Are there any criminal charges pending against you (if so, list below)?
ARREST DATE OFFENSE NAME and LOCATION DISPOSITION STATUS
OF COURT
5 Rev. 9/08
APPLICANT INITIALS: _________
V. LICENSE INFORMATION
List ALL licenses, certifications, or registrations issued to you, by City or State.
Include all Driver Licenses issued to you.
Issuing City or LICENSE TYPE LIC./ CERT./ STATUS EXPIRATION
State REG. NUMBER DATE
(active / not active)
Have any licenses/ certifications/ registrations issued to you ever been suspended, restricted, or revoked;
or have you ever been censured or disciplined in connection therewith? YES NO
If YES, please indicate below in the Comment Section the type of license / certification / registration
along with the reason for suspension, restriction, or revocation.
Are you related to any Department of Buildings employee(s) including through YES NO
marriage? (If yes, please provide the name, title and relationship to the employee)
Comment Section
6 Rev. 9/08
APPLICANT INITIALS: _________
VI. EDUCATION
POST HIGH SCHOOL EDUCATION
FILL IN ALL boxes that apply to you. List education levels pertaining to the applicant’s certification or license. If you
do not have any of the aforementioned, print “N/A” in each education section not used.
DO NOT INCLUDE HIGH SCHOOL
A) DATES ATTENDED
FROM: __________ — __________ TO: __________ — __________ MAJOR : ____________________
(Month) (Year) (Month) (Year)
DID YOU GRADUATE: YES NO DEGREE: AA/AS BA/BS MA/MS PhD
INSTITUTION
STREET ADDRESS
CITY or TOWN
STATE ZIP CODE TELEPHONE _(_____)_ — ________ — _______
COUNTRY (If not United States)
FOREIGN POSTAL CODE
B) DATES ATTENDED
FROM: __________ — __________ TO: __________ — __________ MAJOR : ____________________
(Month) (Year) (Month) (Year)
DID YOU GRADUATE: YES NO DEGREE: AA/AS BA/BS MA/MS PhD
INSTITUTION
STREET ADDRESS
CITY or TOWN
STATE ZIP CODE TELEPHONE _(_____)_ — ________ — _______
COUNTRY (If not United States)
FOREIGN POSTAL CODE
7 Rev. 9/08
APPLICANT INITIALS: _________
CERTIFICATE PROGRAMS
List ALL Certificates/Trainings pertaining to the applicant’s certification or license. If you do not have any of the
aforementioned, print “N/A”
Certificate Name Institution Issued From Date Issued
8 Rev. 9/08
APPLICANT INITIALS: _________
VII. EMPLOYMENT
Start with your present job and list the employment history for each job you intend to use as qualifying experience.
If you had more than eight jobs, add additional data sheets. Fill in every line or indicate N/A.
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
9 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
10 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
11 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
12 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
13 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
14 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
15 Rev. 9/08
APPLICANT INITIALS: _________
A) Dates Employed FROM: TO:
(Month) (Year) (Month) (Year)
Company still in business: YES NO Hours Worked Per Week:
Last Salary $ Hourly Weekly Annually
Job Title(s) & dates held
Civil Service Title(s)
Employer
Street Address
City or Town State Zip Code
Country (If not U.S.)
Foreign Postal Code
Supervisor(s) Name(s)
Supervisor(s) Title(s)
Supervisor(s) license type and license number (if applicable)
Supervisor(s) Telephone Number Fax Number
Reason for leaving
You must list all duties below. If you have supervisory experience, include the number and titles of employees
that you supervised - Use pg 17 if additional space is needed.
16 Rev. 9/08
APPLICANT INITIALS: _________
VIII. COMMENTS SECTION
This section is reserved for any additional comments or facts you may wish to add. If you are explaining or continuing an
answer given in this questionnaire, please identify the question specifically (page number and section). If you do not need to
write any additional comments on this page, write “NO COMMENTS” below. If additional space is needed attach additional
sheets.
17 Rev. 9/08
APPLICANT INITIALS: _________
CERTIFICATION BY THE “APPLICANT” OF THIS QUESTIONNAIRE
WE ADVISE YOU: A MATERIAL FALSE STATEMENT OR OMISSION MADE IN CONNECTION
WITH THIS QUESTIONNAIRE IS SUFFICIENT CAUSE FOR THE CITY OF NEW YORK TO DENY
THE LICENSE BEING SOUGHT TO RESCIND OR REVOKE THE LICENSE HELD. IN ADDITION,
SUCH FALSE SUBMISSION MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO
CRIMINAL CHARGES, INCLUDING NEW YORK STATE PENAL LAW SECTIONS 175.35
(OFFERING A FALSE STATEMENT FOR FILING) AND 210.40 (SWORN FALSE STATEMENT)
AND/OR TITLE 18 U.S.C. SECTION 1001 (FALSE OR FRAUDULENT STATEMENT).
I, , being duly sworn,
(Print Full Name)
state that I have read, understand and to the best of my knowledge responded truthfully, accurately and
completely to each of the questions contained in the attached Questionnaire.
I have read and completed this Questionnaire for the express purpose of inducing the Department of
Buildings to issue a license to me or renew a license already issued to me.
I acknowledge that the City of New York (“the City”) may, by means it deems appropriate, determine the
accuracy and the truth of the statements made in the Questionnaire.
I authorize the City through its employee(s), agent(s) and/or representative(s) to investigate my
background and authorize all persons, companies, schools, governmental agencies or authorities to re-
lease any and all information pertaining to me or submission made by me, documentary or otherwise, as
requested by an appropriate employee, agent, or representative of the City. I understand that information
sought will include a criminal background check, and employment background check, and a Department
of Motor Vehicles background check issued by a Consumer Reporting Agency.
I agree to fully cooperate with the city in its investigation of my background.
(Signature of Applicant) (Date)
Sworn before me this day of , 20___
Notary Public or Commissioner of Deeds
18 Rev. 9/08
APPLICANT INITIALS: _________
