"Employment Agency Renewal Self-certification" - New York City

Employment Agency Renewal 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 January 17, 2020;
  • The latest edition currently provided by the New York City Department of Consumer Affairs;
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Download "Employment Agency Renewal Self-certification" - New York City

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NYC SMALL BUSINESS
DCA LICENSING CENTER
SUPPORT CENTER
42 Broadway, Lobby
New York, NY 10004
90-27 Sutphin Blvd, 4th Floor
Monday-Friday: 9:00 a.m.-5:00 p.m.
Jamaica, NY 11435
Wednesday: 8:30 a.m.-5:00 p.m.
Monday-Friday: 9:00 a.m.-5:00 p.m.
Renewal Unit Telephone: (212) 487-4060
nyc.gov/dca
EMPLOYMENT AGENCY RENEWAL
SELF-CERTIFICATION
Compliance with Employment Agency Laws
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 Renewal Self-Certification” instead. This form is
available at nyc.gov/BusinessToolbox.
If you have not previously submitted to DCA an Employment Agency Self-Certification or
your agency has undergone a change in ownership, you must complete the full
Employment Agency Self-Certification, which is available at nyc.gov/BusinessToolbox.
The owner (e.g., sole proprietor, general partner, director, corporate officer, member, or
shareholder owning 10% or more of company stock) of your agency must complete this form.
Legal Name of Business:
Business’s Trade or
Doing-Business-As (DBA)
Name, if applicable:
DCA License Number:
Employment Agency
Address:
(Building Number, Street Name,
Unit, e.g., Floor, Suite)
Name of Owner:
(e.g., sole proprietor, general
partner, director, corporate officer,
member, or shareholder owning
10% or more of company stock)
Updated 1/17/2020
Page 1 of 7
NYC SMALL BUSINESS
DCA LICENSING CENTER
SUPPORT CENTER
42 Broadway, Lobby
New York, NY 10004
90-27 Sutphin Blvd, 4th Floor
Monday-Friday: 9:00 a.m.-5:00 p.m.
Jamaica, NY 11435
Wednesday: 8:30 a.m.-5:00 p.m.
Monday-Friday: 9:00 a.m.-5:00 p.m.
Renewal Unit Telephone: (212) 487-4060
nyc.gov/dca
EMPLOYMENT AGENCY RENEWAL
SELF-CERTIFICATION
Compliance with Employment Agency Laws
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 Renewal Self-Certification” instead. This form is
available at nyc.gov/BusinessToolbox.
If you have not previously submitted to DCA an Employment Agency Self-Certification or
your agency has undergone a change in ownership, you must complete the full
Employment Agency Self-Certification, which is available at nyc.gov/BusinessToolbox.
The owner (e.g., sole proprietor, general partner, director, corporate officer, member, or
shareholder owning 10% or more of company stock) of your agency must complete this form.
Legal Name of Business:
Business’s Trade or
Doing-Business-As (DBA)
Name, if applicable:
DCA License Number:
Employment Agency
Address:
(Building Number, Street Name,
Unit, e.g., Floor, Suite)
Name of Owner:
(e.g., sole proprietor, general
partner, director, corporate officer,
member, or shareholder owning
10% or more of company stock)
Updated 1/17/2020
Page 1 of 7
I certify the following:
1. I am authorized (e.g., owner, sole proprietor, general partner, director, corporate officer,
member, or shareholder owning 10% or more of company stock) to complete and sign this
Employment Agency Renewal Self-Certification on behalf of the business named on page 1.
2. 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 can access the above laws and rules via nyc.gov/BusinessToolbox. (Scroll to section
“Get Important Information for:” and select Employment Agencies.)
3. 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. I have
completed Appendix A, which includes recent amendments to the Employment
Agency Laws.
4. YOU MUST CHECK A OR B.
A.  I, or a current Employment Agency owner, previously completed the full
Employment Agency Self-Certification, and all of the responses remain true and
accurate.
B.  I, or a current Employment Agency owner, previously completed the full
Employment Agency Self-Certification, and all of the responses remain true and
accurate except for the changes described below.
If you checked B, you must provide an explanation of the changes in the space
below.
Reminder: If you had a change in ownership, you must complete the full
Employment Agency Self-Certification available at nyc.gov/BusinessToolbox.
Updated 1/17/2020
Page 2 of 7
5. If any of the information in this Employment Agency Renewal Self-Certification changes, the
employment agency will inform DCA of those changes in writing.
FAILURE TO RETURN OR FULLY COMPLETE SELF-CERTIFICATION:
If you do not return or fully complete this Employment Agency Renewal Self-Certification or a full
Employment Agency Self-Certification (if you did not submit one previously or your agency had
a change in ownership), DCA may deny your license.
PENALTY FOR FALSE STATEMENTS:
By signing below, I certify that the statements in this Employment Agency Renewal
Self-Certification, including those in Appendix A, are true, correct, and complete. I understand
that falsification of any statement made herein is an offense punishable by a fine or
imprisonment or both.
If you submit this form as an electronically filled-in PDF, you may type your name in the
signature field.
_______________________________ ___________________________
Signature
Print Name
_______________________________ ___________________________
Print Position/Title
Date
Please submit the signed original to DCA and make a copy for your records.
All laws and rules of the City of New York, including the New York City Consumer Protection
Law and Rules, are accessible via nyc.gov/dca.
Updated 1/17/2020
Page 3 of 7
APPENDIX A: RECENT AMENDMENTS TO THE EMPLOYMENT AGENCY LAWS
Section 4: Contracts, Statements of Terms and Conditions,
and Receipts
GBL Section 181
6 RCNY Section 1-05 and 5-259
Contracts
 I understand that the contract must be a separate document from any other form I give to job
applicants. I will not combine the contract with a job application form.
(Check A or B.)
A.  I will use DCA’s model contract as my agency’s contract and give a copy to each job
applicant who applies for my services. The model contract is available for download at
nyc.gov/BusinessToolbox. I am responsible for using the most current version of this
contract, and I will regularly check DCA’s website for updates.
B.  I will not use DCA’s model contract, but will give each job applicant a contract that is
substantially similar to DCA’s model contract and will include all of the following:
Sections 185 and 186 of the GBL AND
The word “Contract” written or printed clearly at the top AND
Name, address, telephone number, and DCA license number of my agency AND
Name of the individual executing the contract on behalf of my agency AND
Name of the job applicant AND
Name, address, mailing address, and telephone number of the employer AND
Anticipated rate of wages or compensation, anticipated hours of work per day and
number of days to be worked per week AND
Fee the job applicant will pay to my agency based on the anticipated wages or
compensation AND
Any provision to the employee and costs associated with such provision AND
Anticipated period of employment and whether it is permanent or temporary AND
Type of work the job applicant will perform AND
Name and address of the person authorizing the hiring of the applicant AND
Payment schedule AND
Notice in 12 point or larger boldface type printed directly above the space reserved in
the contract for the applicant’s signature stating:
NOTICE TO JOB APPLICANT – READ BEFORE SIGNING
Do not sign this contract before you have read it or if any spaces are left blank.
The employment agency must give you a signed copy of this contract at the time
you sign it.
AN EMPLOYMENT AGENCY MAY NOT CHARGE YOU, THE JOB APPLICANT, A FEE
BEFORE REFERRING YOU TO A JOB THAT YOU ACCEPT. IF YOU PAY A FEE
Updated 1/17/2020
Page 4 of 7
BEFORE ACCEPTING A JOB OR PAY A FEE THAT OTHERWISE VIOLATES THE
LAW, YOU MAY DEMAND A REFUND, WHICH SHALL BE REPAID WITHIN SEVEN
DAYS. IF YOU HAVE A COMPLAINT OR NEED MORE INFORMATION, CALL 3-1-1.
Statements of Terms and Conditions
 I understand that the statement of terms and conditions must be a separate document from
any other form I give to job applicants. I will not combine the statement of terms and
conditions with the contract or the job applicant form.
 I understand that I must use DCA’s Terms and Conditions template as my agency’s
statement of terms and conditions and give a copy to each job applicant who executes a
contract for my services. The Terms and Conditions template is available for download at
nyc.gov/BusinessToolbox. I am responsible for using the most current version of this
document, and I will regularly check DCA’s website for updates.
 I understand that my agency must provide to each job applicant a statement of terms and
conditions in the language in which the applicant’s contract was negotiated, provided DCA
has made a template available in that language.
Receipts (Check A or B.)
A.  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. I am responsible for using the most current
version of this receipt, and I will regularly check DCA’s website for updates.
B.  I will not use DCA’s model receipt, but will give each job applicant who pays a fee a
receipt that is substantially similar to DCA’s model receipt and will include all of the
following:
The word “Receipt” written or printed clearly at the top AND
Name of the job applicant AND
Name, address, and DCA license number of my agency AND
Date and amount of the fee AND
Reason for the fee AND
Signature, printed name, and title of the person receiving the deposit, fee, or other
charge on behalf of my agency AND
A notice, set off in a box located and printed directly above the signature of the
person receiving payment, in 12 point or larger boldface capital letters that states:
AN EMPLOYMENT AGENCY MAY NOT CHARGE YOU, THE JOB APPLICANT, A FEE
BEFORE REFERRING YOU TO A JOB THAT YOU ACCEPT. IF YOU PAY A FEE
BEFORE ACCEPTING A JOB OR PAY A FEE THAT OTHERWISE VIOLATES THE
LAW, YOU MAY DEMAND A REFUND, WHICH SHALL BE REPAID WITHIN SEVEN
DAYS. IF YOU HAVE A COMPLAINT OR NEED MORE INFORMATION, CALL 3-1-1.
Updated 1/17/2020
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