"Certification of Licensed Health Care Professional" - New York City

Certification of Licensed Health Care Professional is a legal document that was released by the New York City Department of Consumer Affairs - a government authority operating within New York City.

Form Details:

  • Released on September 22, 2016;
  • The latest edition currently provided by the New York City Department of Consumer Affairs;
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CERTIFICATION OF LICENSED HEALTH
42 Broadway
New York, NY 10004
CARE PROFESSIONAL
Dial 311
(212-NEW-YORK)
The Licensed Health Care Professional must complete this form to
confirm a disability for the General Vendor Licensee requesting
nyc.gov/dca
authorization to use a helper. See the back for information about Section
2-318 of Title 6 of the Rules of the City of New York.
Applicant
Name:
License
Number
(if applicable):
Licensed
Name:
Health Care
___________________________________________
Professional:
Type of Practice:
__________________________________
License No.: _______________________
Phone: (_____) _____ - _______________
Business Address:
______________________________________________
______________________________________________
______________________________________________
I certify the following:
1. I am licensed as a _____________________________________.
2. I examined the Applicant and found that the Applicant has a disability
that impairs the Applicant’s ability to operate a general vending
business.
3. The Applicant’s disability is (choose one):
 Permanent
 Temporary
If the Applicant’s disability is temporary, provide an estimate of its
duration:
__________________________________________________
Updated 09/22/2016
CERTIFICATION OF LICENSED HEALTH
42 Broadway
New York, NY 10004
CARE PROFESSIONAL
Dial 311
(212-NEW-YORK)
The Licensed Health Care Professional must complete this form to
confirm a disability for the General Vendor Licensee requesting
nyc.gov/dca
authorization to use a helper. See the back for information about Section
2-318 of Title 6 of the Rules of the City of New York.
Applicant
Name:
License
Number
(if applicable):
Licensed
Name:
Health Care
___________________________________________
Professional:
Type of Practice:
__________________________________
License No.: _______________________
Phone: (_____) _____ - _______________
Business Address:
______________________________________________
______________________________________________
______________________________________________
I certify the following:
1. I am licensed as a _____________________________________.
2. I examined the Applicant and found that the Applicant has a disability
that impairs the Applicant’s ability to operate a general vending
business.
3. The Applicant’s disability is (choose one):
 Permanent
 Temporary
If the Applicant’s disability is temporary, provide an estimate of its
duration:
__________________________________________________
Updated 09/22/2016
4. The disability impairs the Applicant’s ability to operate a general vending business in the following
manner (please describe with specificity, including the medical facts that support your
certification and attach additional sheets as necessary):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
This certification shall be deemed executed in the City and State of New York and shall be governed by
and construed in accordance with the laws of the State of New York (notwithstanding New York choice of
law or conflict of law principles) and the laws of the United States.
By signing below, I certify that the statements above are true and correct.
__________________________________________________
__________________________________________________
Signature
Print Name
__________________________________________________
Date
A General Vendor Licensee with a disability that impairs the Licensee’s ability to operate a general vending
business may be authorized by the Department of Consumer Affairs to use helpers, as described in Section
2-318 of Title 6 of the Rules of the City of New York.
Definitions:
Disability: a physical or mental impairment that substantially limits one or more major life activities or major
bodily functions and that permanently or temporarily impairs an individual’s ability to operate a general
vending business.
Major life activities: include caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping,
walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking,
communicating, and working.
Major bodily functions: include functions of the immune system, normal cell growth, digestive, bowel,
bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.
Updated 09/22/2016
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