BOARD OF EDUCATION OF THE CITY OF NEW YORK

BOARD OF EDUCATION OF THE CITY OF NEW YORK
OFFICE OF SCHOOL FOOD AND NUTRITION SERVICES
44-36 VERNON BOULEVARD
LONG ISLAND CITY, NEW YORK 11101

Social Security #: ________ ________ _________ E.I.S.#: _____________________

Mr. /Mrs. / Ms.____________________________________________________________________________________ First Name Last Name Middle Initial

Home Address: _________________________________________________________________________ Number/Street City/State Zip

2000-2001
Day School Assignment __________ ____________________________ _____________________ District School Borough

Seniority Date: _____________________ __________ ______ Position: __________________________ Month Day Year

If YES, in what School did you work? ___________ __________________________________________ District School

How many CONSECUTIVE YEARS have you worked in the Summer Breakfast/Lunch Program? _____________

I, HEREBY, CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE
STATEMENTS IN THE FOREGOING APPLICATION ARE TRUE, COMPLETE AND
ACCURATE AND ANY MISREPRESENTATION OF MATERIAL FACTS ON THIS
APPLICATION THROUGH MISSTATEMENTS OR OMISSIONS MAY CAUSE
INVALIDATION OF THIS APPLICATION.

___________________________________________ _________________________
Signature of Applicant Date

I, HEREBY, CERTIFY THAT APPLICANT IS A SUPERVISING SCHOOL AIDE/SCHOOL AIDE
ASSIGNED TO THE ABOVE SCHOOL.

            _____________________________________          __________________________
                            Signature of Principal or                                                Date
                          Designee (Payroll Secretary)

Social Security #: ____ _ E.I.S.#: _________________

Home Address: _________________________________________________________________________ Number/Street City/State Zip

I, HEREBY, CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE
STATEMENTS IN THE FOREGOING APPLICATION ARE TRUE, COMPLETE AND
ACCURATE AND ANY MISREPRESENTATION OF MATERIAL FACTS ON THIS
APPLICATION THROUGH MISSTATEMENTS OR OMISSIONS MAY CAUSE
INVALIDATION OF THIS APPLICATION.

DDF/sy

Social Security #: ________ ________ _________ E.I.S.#: _____________________

Home Address: _________________________________________________________________________ Number/Street City/State Zip

I, HEREBY, CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE STATEMENTS IN THE FOREGOING APPLICATION ARE TRUE, COMPLETE AND ACCURATE AND ANY MISREPRESENTATION OF MATERIAL FACTS ON THIS APPLICATION THROUGH MISSTATEMENTS OR OMISSIONS MAY CAUSE INVALIDATION OF THIS APPLICATION.

DDF/sy

Social Security #: ____ _ E.I.S.#: _________________

I, HEREBY, CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE
STATEMENTS IN THE FOREGOING APPLICATION ARE TRUE, COMPLETE AND
ACCURATE AND ANY MISREPRESENTATION OF MATERIAL FACTS ON THIS
APPLICATION THROUGH MISSTATEMENTS OR OMISSIONS MAY CAUSE
INVALIDATION OF THIS APPLICATION.