Sla Form Fpl1 - Request Form For Fingerprinting Services - Out Of State Residents Only 2010

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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

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