"Employment Agency Self-certification" - New York City

Employment Agency Self-certification 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 19, 2014;
  • The latest edition currently provided by the New York City Department of Consumer Affairs;
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EMPLOYMENT AGENCY SELF-CERTIFICATION
Compliance with Employment Agency Laws
This Self-Certification includes four parts:
 PART I (general information)
 PART II (information about Employment Agency Manager)
 PART III (relevant laws and rules and checklists)
 PART IV (signature and penalty for false statements)
Note: If you place or attempt to place job applicants in theatrical engagements (e.g., actors, singers,
models, directors, writers, musicians), you must complete the “Theatrical Employment Agency Self-
Certification” instead. This form is available at nyc.gov/BusinessToolbox.
The owner (e.g., sole proprietor, general partner, director, corporate officer, or shareholder owning 10%
or more of company stock) of your agency must complete this form.
If the owner is not also the Employment Agency Manager, then the Employment Agency Manager must
complete and certify PART II.
PART I
Legal Name of Business:
DCA License Number,
if applicable:
Applicants for a new license do
not need to complete this field.
Business’s Trade or Doing-
Business-As (DBA) Name,
if applicable:
Employment Agency Address
(Building Number, Street Name,
Unit, e.g., Floor, Suite):
Name of Owner
(e.g., sole proprietor, general
partner, director, corporate
officer, or shareholder owning
10% or more of company stock)
Revised 09/19/14
Page 1 of 20
EMPLOYMENT AGENCY SELF-CERTIFICATION
Compliance with Employment Agency Laws
This Self-Certification includes four parts:
 PART I (general information)
 PART II (information about Employment Agency Manager)
 PART III (relevant laws and rules and checklists)
 PART IV (signature and penalty for false statements)
Note: If you place or attempt to place job applicants in theatrical engagements (e.g., actors, singers,
models, directors, writers, musicians), you must complete the “Theatrical Employment Agency Self-
Certification” instead. This form is available at nyc.gov/BusinessToolbox.
The owner (e.g., sole proprietor, general partner, director, corporate officer, or shareholder owning 10%
or more of company stock) of your agency must complete this form.
If the owner is not also the Employment Agency Manager, then the Employment Agency Manager must
complete and certify PART II.
PART I
Legal Name of Business:
DCA License Number,
if applicable:
Applicants for a new license do
not need to complete this field.
Business’s Trade or Doing-
Business-As (DBA) Name,
if applicable:
Employment Agency Address
(Building Number, Street Name,
Unit, e.g., Floor, Suite):
Name of Owner
(e.g., sole proprietor, general
partner, director, corporate
officer, or shareholder owning
10% or more of company stock)
Revised 09/19/14
Page 1 of 20
Name of Employment Agency
Manager, if different from
Owner:
Employment Agency Manager
Home Address:
I certify the following:
1.  I am the owner (e.g., sole proprietor, general partner, director, corporate officer, or shareholder
owning 10% or more of company stock).
2.  I have read and understand that I am responsible for complying with the following laws and
rules:
 Article 11 of the New York General Business Law (GBL) beginning at Section 170
 Title 20 of the New York City Administrative Code (Code) at Chapter 1 beginning at Section
20-101 and Chapter 5 Sections 20-700 to 20-706 and 20-770 to 20-774
 Title 6 of the Rules of the City of New York (6 RCNY) at Chapter 1 beginning at Section 1-01
and Chapter 5 Sections 5-06 to 5-12, 5-21, 5-24, and 5-241 to 5-258
 Title 8 of the Code Sections 8-102, 8-107, and 8-107.1
 Title VII of the Civil Rights Act of 1964 beginning at Section 2000e [Section 701]
 Executive Law Article 15 Human Rights Law Sections 292, 296, and 296-b
 All relevant federal, state, and City laws which apply to my business
 I understand that I can access the above laws and rules via nyc.gov/BusinessToolbox.
3.  I understand that I am responsible for knowing and complying with the most current laws,
including any amendments and updates made to the laws that are relevant to my business.
Revised 09/19/14
Page 2 of 20
PART II
Information about Employment Agency Manager
Employment Agencies must have an Employment Agency Manager who is responsible for directing and
operating the placement activities of the employment agency. This person can be the owner. The person
(either the owner or another individual) who will act as the agency’s manager must complete and
certify Part II.
The Department of Consumer Affairs (DCA) will consider this Self-Certification incomplete if you
do not complete and certify PART II.
Practical Experience: State your experience as a placement employee, vocational counselor, or in related
activities that indicate your competence to operate the placement activities of this agency. Attach
additional papers as necessary.
Name of
Address
Telephone
Start/End Dates
Position
Employer
and Duties
Revised 09/19/14
Page 3 of 20
Educational Experience:
Name of School
Address
Start/End Dates
Type of Coursework /
Degree / or
Certification
Obtained
Have you previously worked at, owned, operated, or had a financial interest in an employment
agency issued violations, shut down, or padlocked by the New York City Department of Consumer
Affairs (DCA) or by the New York State Department of Labor?
 Yes
 No
If you answered Yes, please enter requested information below.
Legal Name of Employment Agency:
Employment Agency Address (Building Number,
Street Name, Unit, e.g., Floor, Suite):
DCA License Number:
Relationship to Business:
By signing below, I, the Employment Agency Manager, certify that the statements in PART II are true
and correct.
If you submit this form as an electronically filled-in PDF, you may type your name in the signature field.
_______________________________
___________________________
Signature
Print Name
_______________________________
___________________________
Title
Date
Revised 09/19/14
Page 4 of 20
PART III
This part of the Self-Certification covers New York State and City laws relevant to employment
agencies. Please read each section carefully. Included in each section are checklists. You must check
each requirement that applies to your agency to certify that you understand and will comply with
the requirement.
Important: If you submit an incomplete Self-Certification, your application will be denied or the
Department of Consumer Affairs (DCA) may request additional information.
Section 1: Settlement Agreements/Orders
Check the box or boxes that apply to you.
 I have entered into an Agreement, Settlement Agreement, Consent Judgment Order, or Consent Order
(collectively referred to as “settlement agreement”) with DCA.
 My agency has entered into an Agreement, Settlement Agreement, Consent Judgment Order, or
Consent Order (collectively referred to as “settlement agreement”) with DCA.
 I am a new applicant, and this Section does not apply to me or my agency.
 I am a renewing licensee, and this Section does not apply to me or my agency.
If you indicated that you or your agency entered into a settlement agreement with DCA, you must
complete these additional checklists about Contracts and Receipts.
 I agreed to use DCA’s model contract, or one that is substantially similar, as my agency’s contract
with job applicants. I have complied with this requirement. Beginning on the date of this Self-
Certification, I will use DCA’s model contract as my agency’s contract with job applicants. The model
contract is available for download at nyc.gov/BusinessToolbox.
 I agreed to use DCA’s model receipt, or one that is substantially similar, to give to each job applicant
who pays a fee as confirmation of payment. I have complied with this requirement. Beginning on the date
of this Self-Certification, I will use DCA’s model receipt as my agency’s receipt and give a receipt to
each job applicant who pays a fee as confirmation of payment. The model receipt is available for
download at nyc.gov/BusinessToolbox.
Revised 09/19/14
Page 5 of 20