Transcription of PHYSICAL EXAMINATION FORM - New York City
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PHYSICAL EXAMINATION FORM - New York City
LIC-62 10/2017 Page 1 PHYSICAL EXAMINATION FORM This form must be completed within 90 days prior to submission *In accordance with Federal and State Laws, the New york city Department of Buildings requires that all applicants for licenses/license holders provide their Social Security Number (SSN). DOB will use the SSN to conduct background investigations and maintain accurate license and related records. This information may be shared with other government agencies, consistent with applicable laws and Departmental policy or with the SSN holder s written permission, but will otherwise be kept confidential. The specific statutory authority for requiring SSN s is in the following: Federal Law-Privacy Act of 1974 1 Applicant Information First Name Last Name Date of Birth *Social Security # Home Address Phone Number city State Zip License Type: License Number (if, licensed) 2 Physician TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print) 3 General Health Assessment Fitness is being physically and mentally capable of undertaking the tasks that an individual is required to carry out and is licensed to engage in by the NYC Department of Buildings.
Mentally capable means to lack any medical conditions that might impair cognitive function or emotional state to the extent that the applicant cannot complete the responsibilities of the license. Medically fit applicants must not be suffering from medical conditions or undergoing any medical treatment that is likely to cause sudden loss of
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