Countywide Bee-Line ParaTransit Innovative - Westchester County ...

Contract #: __________________________________
Name of Consultant, Contractor, Lessee, or Licensee:
__________________________________
CRIMINAL BACKGROUND DISCLOSURE
FORM AND CERTIFICATION
If this form is being completed by a subconsultant, subcontractor, sublessee, or
sublicensee, please consider all references in this form to “consultant, contractor,
lessee, or licensee” to mean “subconsultant, subcontractor, sublessee, or sublicensee”
and check here: ____________________
I, _______________________________________________, certify that I am a
(Name of Person Signing Below)
principal or a representative of the Consultant, Contractor, Lessee, or Licensee and I
am authorized to complete and execute this Criminal Background Disclosure Form and
Certification. I certify that I have asked each Person Subject to Disclosure the following
questions:
• Have you or your company ever been convicted of a crime (all felonies
and misdemeanors as defined under the New York State Penal Law or
the equivalent under Federal law or the laws of any other State)
including, but not limited to, conviction for commission of fraud,
embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements or receiving stolen property
• Are you or your company subject to any pending criminal charges (all
felonies and misdemeanors as defined under the New York State Penal
Law or the equivalent under Federal law or the laws of any other State)
I certify that the names and titles of Persons Subject to Disclosure who refused to
answer either of the questions above are:
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
4. ________________________________________________________________
5. ________________________________________________________________
(If more space is needed, please attach separate pages labeled “REFUSED to Answer -
Continued.”)