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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: _________

								
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