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New York City - Fair Chance Act Form

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Bill de Blasio, Mayor | Carmelyn P. Malalis, Commissioner/Chair | | @NYCCHR Fair Chance Act Notice After extending a conditional offer of employment, we checked your criminal record. Based on the enclosed check, we have reservations about hiring you for the position of _________________________, and may decide to retract our job offer. Below explains why. We invite you to provide us with any information that could help us decide to offer you the job. If you choose to provide us with additional information you have ___________ days (must be at least three business days) from the date you receive this to do so. If you wish to respond, please contact _________________________________________________. In your response, you may: • Tell us about any errors on your criminal record; • Give us any additional information you'd like us to consider after reviewing this notice. The following factors were considered, as required by Article 23-A of the New York State Correction Law, before making our determination: A. c The government encourages employers to hire people with criminal records. B. c The specific duties and responsibilities of the job, which are: 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. _________________________________________________________________________________________ C. c We believe your record impacts your fitness or ability to perform these duties and responsibilities because: D. c How long ago your criminal activity, not your conviction, occurred: _____ years _____ months E. c Your age when your criminal activity, not your conviction, occurred: _____ years old F. c The seriousness of the conduct that led to your criminal record, which is: G. c Your evidence of rehabilitation and good conduct, which is listed below. 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ If you have additional documents we should consider, please send them, including evidence that you attended school, job training, or counseling; or are involved with your community. They can include letters from people who know you, like teachers, counselors, supervisors, clergy, and parole or probation officers. H. c Our legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public, which is: I. c Your certificate(s) of relief or certificate of good conduct shows that you are rehabilitated. If you did not have a certificate, we did not hold that against you. Based on these factors, we may deny you the job because (choose one or both below): We believe there is a direct relationship between your criminal record and the job we offered to you, and the factors listed above do not lessen that relationship because: Your criminal record creates an unreasonable risk to specific persons, the general public, or our property because: Article 23-A Evaluation Form ______________________________________________ Applicant Name

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