Physical Culture Establishment Questionnaire Form

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CITY OF NEW YORK 
BOARD OF STANDARDS AND APPEALS 
th 
40 Rector Street, 9 
Floor 
New York, New York 10006­1705 
Phone: (212) 788­8500 FAX: (212)788­8769 
PHYSICAL CULTURE ESTABLISHMENT QUESTIONNAIRE FORM 
Please complete and return to: 
Board of Standards and Appeals 
th 
40 Rector Street, 9 
Floor 
New York, New York 10006 
COMPANY NAME:_______________________________________ 
AKA/DBA 
__________________ 
ADDRESS:_______________________________________________          APPLICATION NO._______________________________________ 
ADDRESS OF PROPOSED PHYSICAL CULTURE ESTABLISHMENT:____________________________________________________________ 
LIST ALL THE PRINCIPALS INVOLVED 
Include owners, partners, directors, operators, and program managers/directors of this specific facility.  If necessary, use additional sheets to list all principals. 
EACH OF THE INDIVIDUALS LISTED HERE MUST COMPLETE A PRINCIPAL QUESTIONNAIRE FORM. 
PRINCIPALS 
DOB 
SS# 
1) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
2) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
3) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
4) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
5) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
6) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
7) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
8) 
NAME: 
/          /_____ 
__________________________ 
HOME ADDRESS: 
POSITION HELD:  ___________________________ 
IT IS MY UNDERSTANDING THAT THIS QUESTIONNAIRE WILL BECOME PART OF THE CASE FILE FOR THE APPLICATION   
AT THE BOARD OF STANDARDS AND APPEALS. 
SIGNATURE: 
DATE:_________________________________________________ 
NAME: 
TITLE:_________________________________________________ 
(Please type or print) 
Subscribed and sworn to before me this___________________________ day of ________________________, 20______. 
A material false statement willfully or fraudulently made in connection with this application and the accompanying principal questionnaire(s) may 
result in disqualification for approval of a variance or a special permit, and in addition may subject the person making the false statement to criminal 
charges.
American LegalNet, Inc.

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