All documents must be accurate and uploaded with this online application in order to efficiently process this registration. Documents not submitted will result in a incomplete registration and you will be required to start a new registration.
For Mac Users: This request form may not function property with your Safari web browser. We are hoping to resolve this problem soon. In the meantime, please download the free Mozilla Firefox web browser in order to use this form in the interim. For more information on Mozilla Firefox please visit http://www.mozilla.org/. To download the current version of Mozilla Firefox for Macs, please click on the following link: http://download.mozilla.org/?product=firefox-5.0.1&os=osx&lang=en-US.
All Fields are Required
1. Agency Information
A. Agency Name:
B. Owner's First Name:Owner's Last Name:
City: State: Zip:
E. Temp Reference No. (See bottom left of the SIA1 Form for this number):
2. Document Upload:
Upload State issued photo identification:
Upload proof of NYC business address or proof of filing with NYS Secretary of State:
Upload NYC workers compensation certificate or waiver:
Upload proof of professional liability insurance certificate (PE/RA only):
Note: All upload files cannot be bigger than 3 MB combine. Upload FAQs