NYS Liquor Authority / Division of Alcoholic Beverage Control
Request for Card Scan Services ‐ Information Form‐(For Out of State Residents)
Instructions for applicant: Complete form and submit with two FBI (blue) fingerprint cards, a copy of
your Application Receipt and your fee made out to “L1 Enrollment Services” to the address below.
DO NOT BEND CARD WHEN MAILING!!
MAIL TO:
L-1 ESD/LIVESCAN PROCESSING UNIT
1650 WABASH AVE, SUITE D
ATT: CARDSCAN DEPT
SPRINGFIELD, ILLINOIS, 62704
Please Print Clearly
ORI: NY922217Z
Contributor Agency: NYS Liquor Authority
Agency Code: 700208L
License Serial #:
Premises Name: ________________________________________ DBA: ___________________________________
Premises Address: ______________________________________________________________________________
Premises City, State & Zip: ________________________________________________________________________
New Submission Resubmission
Check one:
If resubmission, list TCN Number here:
Name of Applicant: Last _________________________________First _________________________ M.I. _______
Alias / Maiden Name:
_________________________________________________________________ _ ______
Street Address:
________________________________________________________________________
City, State, & Zip:
________________________________________________________________________
Date of Birth: ____________________ Age: ______
Sex: Male Female R ace: _______________
Ethnicity: Hispanic Non Hispanic
Height: _______ft. _______in.
Weight: _________lbs.
Skin Tone: ______________________
Eye Color: _________________
Hair Color: ___________________
State / Country of Birth: _______________________________ Country of Citizenship: _____________________
Payment Section:
• Payment options include: personal or business check, certified check, bank check, or
money order made out to "L‐1 Enrollment Services” for $105.00.
For Official Use Only:
L‐1 Billing Account Number:
SLA Form FPL1, Rev043010