Form CA-L21 "Home Improvement Salesperson License Application" - Suffolk County, New York

What Is Form CA-L21?

This is a legal form that was released by the Department of Labor, Licensing & Consumer Affairs - Suffolk County, New York - a government authority operating within New York. The form may be used strictly within Suffolk County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Department of Labor, Licensing & Consumer Affairs - Suffolk County, New York;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CA-L21 by clicking the link below or browse more documents and templates provided by the Department of Labor, Licensing & Consumer Affairs - Suffolk County, New York.

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Download Form CA-L21 "Home Improvement Salesperson License Application" - Suffolk County, New York

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Steven Bellone
Frank Nardelli
Suffolk County Executive
Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600
FAX (631) 853-4825
HOME IMPROVEMENT SALESPERSON LICENSE APPLICATION
YOUR SALES APPLICATION WILL BE RETURNED UNLESS YOU PROVIDE:
“Authorization from the
1. A totally completed application. YOU MUST ATTACH A PASSPORT
PHOTO.
person who holds the home improvement
license”
must be completed and signed by the home improvement
Your
license holder.
Photo
2. A totally completed Affirmation (Page 2). Be certain to answer all questions. Sign and date at the bottom.
3. Applicant Background (Pages 3/4) must be completed and
signed.
If you answer YES to any of the
questions, you must provide a detailed explanation as well as any pertinent
documentation.
4.
A copy of your NYS driver’s license or NYSDMV non-driver’s
identification.
The fee for an identification card is fifty dollars ($50.00) per annum
Applications may be submitted Mon-Fri, 9:00 am-4:00 pm. Licenses are issued by appointment.
Please Print – Answer all questions. Immediate notice should be given of any change of address.
Last Name
First Name
Initial
Business Name
Address
-
Number and Street
Address
- Number and Street
City
State
Zip
City
State
Zip
Telephone Number (including area code)
Type of Business
___Corporation
___Partnership
Home:
Business:
___Sole Proprietorship ___Other
Cell:
Fax:
Date of Birth
Height
Weight
Social Security Number
Month
Day
Year
Ft.
In.
Lbs.
Email Address
1. Have you ever been licensed by this agency? ___No
Previous Employers (List last three, with most recent first)
___Yes, License # ___________________________
Firm ______________________________________________
Address____________________________________________
2. Are you now an officer or principal in a Home Improvement
Co. actively engaged in business in the County of Suffolk?
Dates ___________________ Telephone ______________
___No ___Yes, Name of Firm(s)
Firm ______________________________________________
_____________________________________________
Address____________________________________________
3. Have you ever been an officer, principal, or employed in a
Dates ___________________ Telephone ______________
Home Improvement Company? ___No ___Yes, Name firm
Firm _______________________________________________
& capacity. ________________________________________
Address_____________________________________________
___________________________________________________
Dates ___________________ Telephone ______________
4.
Have you ever been convicted of a violation of law, other than
From the person who holds the Home Improvement License
a traffic violation? ___No ___Yes If yes, explain:
I hereby authorize ___________________________________
__________________________________________________
to represent ________________________________________
__________________________________________________
as a salesperson
_____________________________
__________________________________________________
Signature
Home Improvement License Number ____________________
Privacy Act Statement: Pursuant to the Federal Privacy Act of 1974, as amended, the disclosure of Social Security numbers for applicants is mandatory and is required
by 42 USCS § 666(a)(I3), New York State General Obligation Law § 3-503, and Suffolk County Law § 563.5 and/or SCC 239, and/or sec 275-3A, and/or SCC 313-18A,
and/or SCC 361-3A and/or SCC 391, and/or SCC 460-5, and/or SCC
483.
Such numbers disclosed on the application are requested for the administration of Title IV-D of
the Social Security Act (Child Support Enforcement Act) and related provisions of State
law.
Such numbers will be used by the Department of Labor, Licensing, &
Consumer Affairs to facilitate application processing and to maintain a uniform system of identifying
applicants.
DECLARATION (To be completed by applicant): I declare under penalties of the Penal Law, that I prepared this Application and that the
statements contained therein are, to the best of my knowledge and belief, true, correct and that I have not knowingly and willfully made a
false statement or given information which I know to be false in connection therewith.
Signed _______________________________________________________ Date _______________________________
CA-L21 7/15
Steven Bellone
Frank Nardelli
Suffolk County Executive
Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600
FAX (631) 853-4825
HOME IMPROVEMENT SALESPERSON LICENSE APPLICATION
YOUR SALES APPLICATION WILL BE RETURNED UNLESS YOU PROVIDE:
“Authorization from the
1. A totally completed application. YOU MUST ATTACH A PASSPORT
PHOTO.
person who holds the home improvement
license”
must be completed and signed by the home improvement
Your
license holder.
Photo
2. A totally completed Affirmation (Page 2). Be certain to answer all questions. Sign and date at the bottom.
3. Applicant Background (Pages 3/4) must be completed and
signed.
If you answer YES to any of the
questions, you must provide a detailed explanation as well as any pertinent
documentation.
4.
A copy of your NYS driver’s license or NYSDMV non-driver’s
identification.
The fee for an identification card is fifty dollars ($50.00) per annum
Applications may be submitted Mon-Fri, 9:00 am-4:00 pm. Licenses are issued by appointment.
Please Print – Answer all questions. Immediate notice should be given of any change of address.
Last Name
First Name
Initial
Business Name
Address
-
Number and Street
Address
- Number and Street
City
State
Zip
City
State
Zip
Telephone Number (including area code)
Type of Business
___Corporation
___Partnership
Home:
Business:
___Sole Proprietorship ___Other
Cell:
Fax:
Date of Birth
Height
Weight
Social Security Number
Month
Day
Year
Ft.
In.
Lbs.
Email Address
1. Have you ever been licensed by this agency? ___No
Previous Employers (List last three, with most recent first)
___Yes, License # ___________________________
Firm ______________________________________________
Address____________________________________________
2. Are you now an officer or principal in a Home Improvement
Co. actively engaged in business in the County of Suffolk?
Dates ___________________ Telephone ______________
___No ___Yes, Name of Firm(s)
Firm ______________________________________________
_____________________________________________
Address____________________________________________
3. Have you ever been an officer, principal, or employed in a
Dates ___________________ Telephone ______________
Home Improvement Company? ___No ___Yes, Name firm
Firm _______________________________________________
& capacity. ________________________________________
Address_____________________________________________
___________________________________________________
Dates ___________________ Telephone ______________
4.
Have you ever been convicted of a violation of law, other than
From the person who holds the Home Improvement License
a traffic violation? ___No ___Yes If yes, explain:
I hereby authorize ___________________________________
__________________________________________________
to represent ________________________________________
__________________________________________________
as a salesperson
_____________________________
__________________________________________________
Signature
Home Improvement License Number ____________________
Privacy Act Statement: Pursuant to the Federal Privacy Act of 1974, as amended, the disclosure of Social Security numbers for applicants is mandatory and is required
by 42 USCS § 666(a)(I3), New York State General Obligation Law § 3-503, and Suffolk County Law § 563.5 and/or SCC 239, and/or sec 275-3A, and/or SCC 313-18A,
and/or SCC 361-3A and/or SCC 391, and/or SCC 460-5, and/or SCC
483.
Such numbers disclosed on the application are requested for the administration of Title IV-D of
the Social Security Act (Child Support Enforcement Act) and related provisions of State
law.
Such numbers will be used by the Department of Labor, Licensing, &
Consumer Affairs to facilitate application processing and to maintain a uniform system of identifying
applicants.
DECLARATION (To be completed by applicant): I declare under penalties of the Penal Law, that I prepared this Application and that the
statements contained therein are, to the best of my knowledge and belief, true, correct and that I have not knowingly and willfully made a
false statement or given information which I know to be false in connection therewith.
Signed _______________________________________________________ Date _______________________________
CA-L21 7/15
Steven Bellone
Frank Nardelli
Suffolk County Executive
Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600
FAX (631) 853-4825
STATE OF NEW YORK
)
COUNTY OF SUFFOLK
) ss:
AFFIRMATION
(Name)
_____________________________________________________
(Company Name)
___________________________________________________
1. You must check either (A) or (B)
(A) I affirm that there have never been any judgments filed against the above named individual
applicant or firm.
(B) I affirm that all judgments against me have been
discharged,
are being appealed, or being paid according
to agreed scheduled payments with creditors and that there are no unsatisfied or unnegotiated judgments
against either the above named individual applicant or firm.
2. I hereby acknowledge that I have been advised, and am fully aware, that Suffolk County Code Chapter
563 requires that any individual who negotiates or offers to negotiate a contract for the above named
licensee with a consumer, or solicits or otherwise endeavors to procure a contract from a consumer on
behalf of the above named licensee, whether or not such individual is an employee of the above named
licensee, will first obtain an identification card from the Suffolk County Department of Labor, Licensing,
& Consumer Affairs.
3. Briefly describe work to be
performed:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________
Individual’s Name and Title
_________________________________________
Company Name
AFFIRMATION (To be completed by Applicant): I AFFIRM UNDER PENAL TIES OF THE PENAL LAW,
THAT I PREPARED THIS APPLICATION AND THAT THE STATEMENTS CONTAINED HEREIN ARE,
TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE AND CORRECT AND THAT I HAVE NOT
KNOWINGLY AND WILLFULLY MADE A FALSE STATEMENT OR GIVEN INFORMATION WHICH I
KNOW TO BE FALSE IN CONNECTION HEREWITH.
Signed _________________________________ Date ____________________________
Steven Bellone
Frank Nardelli
Suffolk County Executive
Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
P.O. Box 6100, Hauppauge, NY 11788-0099 (631) 853-4600
FAX (631) 853-4825
APPLICANT BACKGROUND INFORMATION
Your Name __________________________________________________
YOU MUST ANSWER ALL OF THE FOLLOWING QUESTIONS AND SIGN THIS FORM. IF YOU
ANSWER “YES” TO ANY OF THE QUESTIONS, PLEASE PROVIDE A DETAILED EXPLANATION ON A
SEPARATE SHEET.
(1) Have you ever been convicted of a crime or offense of any kind (other than
traffic or parking violations) or entered a plea of guilty or nolo contendere?
Y____ or N____
(2) Are any criminal charges currently pending against you?
Y____ or N____
(3) Are you now, or were you ever on parole or probation? If YES, you MUST
provide a letter of good standing from your parole/probation officer.
Y____ or N____
(4) Have you ever been the subject of any investigation by a federal, state or local
agency (other than a routine background investigation for employment purposes)?
Y____ or N____
(5) Have you ever been cited for contempt of any court or legislative, civil
or criminal investigative body or grand jury?
Y____ or N____
(6) Have you, or any business in which you are or were an owner, officer, director or
partner, been the subject of any criminal or administrative investigation?
Y____ or N____
(7) Are there any liens or judgments against you or any business in which you are
or were an owner, officer, director or partner?
Y____ or N____
(8) Were you, or any business in which you are or were an owner, officer,
director or partner, ever involved in a bankruptcy proceeding? If yes,
where and when ___________________________________________________
Y____ or N____
(9) Are there any tax liens currently assessed or pending against you or any business
in which you are or were an owner, officer, director or partner, or any real property
in which you have a beneficial or legal interest?
Y____ or N ____
(10) How long have you resided at your current address?
____Yrs.___Mths.
(11) Have you resided outside the State of New York for more than 180 days
in the last calendar year?
Y____ or N____
If so, please indicate below your out of state residence address:
______________________________________________________________________________________
(12) Have you been conducting business under the present business name,
and if so, where? _________________________________________________
Y____ or N____
(13) Do you own or have any interest in real property that has been cited for health,
safety or environmental violations by federal, state or local authorities?
Y____ or N____
(14) Are you in arrears on any child support and/or maintenance obligations?
Y____ or N____
(15) Bank Accounts for this business:
Bank Name & Location: _______________________________________________________
Bank Account #: ______________________
Date Opened: ________________________
NOTE: A LICENSE WILL NOT BE ISSUED WITHOUT A VALID BANK ACCOUNT.
(16) Name of CPA, if any: ________________________________________________________
Name of corporate attorney, if any: ______________________________________________
(17) Have you or any immediate family member ever been involved in a business which had a license issued by
this Office? Yes ___ No ___ License # _____________ Date Issued_________ Expiration Date ________
Was this license suspended or revoked? Yes___ No___ Date Suspended________ Date Revoked________
(18) Have you or any immediate family member ever been involved in a business which had a license issued by:
New York City? Yes___ No___ License #__________Date Issued__________ Expiration Date__________
Was this license suspended or revoked? Yes___ No___ Date Suspended________ Date Revoked_________
Nassau County? Yes___ No___ License #__________Date Issued__________ Expiration Date__________
Was this license suspended or revoked? Yes___ No___ Date Suspended________ Date Revoked_________
Any other local municipalities?
Yes___ No___ License # ________________ Date Issued_____________ Expiration Date___________
Was this license suspended or revoked? Yes___ No___ Date Suspended________ Date Revoked_________
NOTE: ALL ANSWERS AND RESPONSES WILL BE CHECKED AND VERIFIED
VIA COMPUTER SEARCH AND OTHER INVESTIGATIVE METHODS.
AFFIRMATION (to be completed by Applicant): I AFFIRM UNDER PENALTIES OF THE PENAL LAW, THAT
I PREPARED THIS APPLICATION AND THAT THE STATEMENTS CONTAINED HEREIN ARE, TO THE
BEST OF MY KNOWLEDGE AND BELIEF, TRUE AND CORRECT AND THAT I HAVE NOT KNOWINGLY
AND WILLFULLY MADE A FALSE STATEMENT OR GIVEN INFORMATION WHICH I KNOW TO BE
FALSE IN CONNECTION HEREWITH.
Signed__________________________________________________ Date_______________________
CA-L1
2/15
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