"Order of Protection Acknowledgement (Criminal History 4)" - New York City

Order of Protection Acknowledgement (Criminal History 4) is a legal document that was released by the New York City Department of Correction - a government authority operating within New York City.

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ORDER OF PROTECTION ACKNOWLEDGEMENT
Name:
Exam #:
List #:
The purpose of this form is to obtain any information regarding the issuance of any “Order of Protection” by you or
against you. Applicants may seek the advice of counsel prior to responding to the questions contained in this form.
1. Have you ever had an “Order of Protection” taken out against you in any court, anywhere
including a military tribunal? Indicate:
YES
NO
2. Have you ever taken out an “Order of Protection” against anyone in any court, anywhere,
including a military tribunal? Indicate:
YES
NO
If you answered "yes" to any of the above questions, provide a detailed explanation on a 17b form
(including who, what, where, why, and how the incident transpired).
WARNING:
SECTION 1151.90 OF THE ADMINISTRATIVE CODE OF THE CITY OF NEW YORK AND SECTION 210.45 OF
THE PENAL LAW MAKE IT A CRIME TO KNOWINGLY FALSIFY ANY INFORMATION ON THIS FORM, AND
ANY APPLICANT WHO KNOWINGLY FALSIFIES ANY SUCH INFORMATION MAY BE PUNISHED BY A FINE,
IMPRISONMENT OR BOTH. IN ADDITION, KNOWLINGLY FALSIFYING ANY MATERIAL / INFORMATION ON
THIS DOCUMENT WILL AUTOMATICALLY CAUSE DISQUALIFICATION OF THE APPLICANT.
DECLARATION (BY APPLICANT)
I DECLARE THAT I HAVE READ THE ABOVE WARNING AND THAT THE STATEMENTS CONTAINED
HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Date:
Signature:
Criminal History 4
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * Bulova Corporate Center 75-20 Astoria Blvd East, East Elmhurst, NY 11370
ORDER OF PROTECTION ACKNOWLEDGEMENT
Name:
Exam #:
List #:
The purpose of this form is to obtain any information regarding the issuance of any “Order of Protection” by you or
against you. Applicants may seek the advice of counsel prior to responding to the questions contained in this form.
1. Have you ever had an “Order of Protection” taken out against you in any court, anywhere
including a military tribunal? Indicate:
YES
NO
2. Have you ever taken out an “Order of Protection” against anyone in any court, anywhere,
including a military tribunal? Indicate:
YES
NO
If you answered "yes" to any of the above questions, provide a detailed explanation on a 17b form
(including who, what, where, why, and how the incident transpired).
WARNING:
SECTION 1151.90 OF THE ADMINISTRATIVE CODE OF THE CITY OF NEW YORK AND SECTION 210.45 OF
THE PENAL LAW MAKE IT A CRIME TO KNOWINGLY FALSIFY ANY INFORMATION ON THIS FORM, AND
ANY APPLICANT WHO KNOWINGLY FALSIFIES ANY SUCH INFORMATION MAY BE PUNISHED BY A FINE,
IMPRISONMENT OR BOTH. IN ADDITION, KNOWLINGLY FALSIFYING ANY MATERIAL / INFORMATION ON
THIS DOCUMENT WILL AUTOMATICALLY CAUSE DISQUALIFICATION OF THE APPLICANT.
DECLARATION (BY APPLICANT)
I DECLARE THAT I HAVE READ THE ABOVE WARNING AND THAT THE STATEMENTS CONTAINED
HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Date:
Signature:
Criminal History 4
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * Bulova Corporate Center 75-20 Astoria Blvd East, East Elmhurst, NY 11370