"Declaration of Incarcerated Associations Form (Criminal History 7)" - New York City

Declaration of Incarcerated Associations Form (Criminal History 7) 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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CITY OF NEW YORK
DEPARTMENT OF CORRECTIONS
DECLARATION OF INCARCERATED ASSOCIATIONS
Are you related to or associated with anyone who was ever incarcerated or is currently incarcerated? If yes,
provide the information below. Be sure to include the person’s full name, your relationship to the person and
date and place of incarceration (if known). Have you ever had contact with any incarcerated individual, for
example: phone calls, sending mail/ e-mail, depositing money into an account or visited any inmate in any city,
state or federal prison? If yes, provide the information below.
INDIVIDUAL’S NAME
RELATIONSHIP
DATE & PLACE OF INCARCERATION
TYPE OF CONTACT
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
SECTION 1151.90 OF THE ADMINISTRATIVE CODE OF THE CITY OF NEW YORK AND 210.45 OF THE PENAL
LAW MAKES IT A CRIME TO KNOWINGLY FALSIFY INFORMATION ON THIS FORM. ANY APPLICANT WHO
KNOWINGLY FALSIFIES ANY SUCH INFORMATION MAY BE PUNISHED BY A FINE, IMPRISONMENT OR BOTH.
IN ADDITION, KNOWINGLY FALSIFYING ANY INFORMATION ON THIS DOCUMENT WILL AUTOMATICALLY
CAUSE YOU TO BE DISQUALIFIED FROM EMPLOYMENT.
DECLARATION (BY APPLICANT)
I hereby attest that all of the statements herein are true under the penalty of perjury and its related offenses pursuant to Section 210 of
the Penal Law.
Name: ____________________________________________ Exam #: ____________________ List #: ____________________
Position Sought:
CORRECTION OFFICER
S.S#: ____________________________________
Date:
Signature:
Sworn to before me this ___________ day of __________________________, 20_______.
Notary Public / Commissioner of Deeds
______________________________________
Criminal History 7
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * Bulova Corporate Center 75-20 Astoria Blvd East, East Elmhurst, NY 11370
CITY OF NEW YORK
DEPARTMENT OF CORRECTIONS
DECLARATION OF INCARCERATED ASSOCIATIONS
Are you related to or associated with anyone who was ever incarcerated or is currently incarcerated? If yes,
provide the information below. Be sure to include the person’s full name, your relationship to the person and
date and place of incarceration (if known). Have you ever had contact with any incarcerated individual, for
example: phone calls, sending mail/ e-mail, depositing money into an account or visited any inmate in any city,
state or federal prison? If yes, provide the information below.
INDIVIDUAL’S NAME
RELATIONSHIP
DATE & PLACE OF INCARCERATION
TYPE OF CONTACT
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
_____________________ __________________ __________________________ ___________________
SECTION 1151.90 OF THE ADMINISTRATIVE CODE OF THE CITY OF NEW YORK AND 210.45 OF THE PENAL
LAW MAKES IT A CRIME TO KNOWINGLY FALSIFY INFORMATION ON THIS FORM. ANY APPLICANT WHO
KNOWINGLY FALSIFIES ANY SUCH INFORMATION MAY BE PUNISHED BY A FINE, IMPRISONMENT OR BOTH.
IN ADDITION, KNOWINGLY FALSIFYING ANY INFORMATION ON THIS DOCUMENT WILL AUTOMATICALLY
CAUSE YOU TO BE DISQUALIFIED FROM EMPLOYMENT.
DECLARATION (BY APPLICANT)
I hereby attest that all of the statements herein are true under the penalty of perjury and its related offenses pursuant to Section 210 of
the Penal Law.
Name: ____________________________________________ Exam #: ____________________ List #: ____________________
Position Sought:
CORRECTION OFFICER
S.S#: ____________________________________
Date:
Signature:
Sworn to before me this ___________ day of __________________________, 20_______.
Notary Public / Commissioner of Deeds
______________________________________
Criminal History 7
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * Bulova Corporate Center 75-20 Astoria Blvd East, East Elmhurst, NY 11370