Request for NYS Fingerprinting Services ‐ Information Form
Request for NYS Fingerprinting Services ‐ Information Form
Instructions for applicant: Complete this form and visit
Instructions for applicant: Complete this form and visit
to schedule an appointment for fingerprinting. Remember to bring this form and required forms of
to schedule an appointment for fingerprinting. Remember to bring this form and required forms of
identification to your fingerprinting appointment.
identification to your fingerprinting appointment.
REMINDERS
REMINDERS
You will be notified after the submission of your application to schedule your electronic
You will be notified after the submission of your application to schedule your electronic
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fingerprinting through L1 Enrollment Services.
fingerprinting through L1 Enrollment Services.
Everything submitted in support of this application must be identified with the name and
Everything submitted in support of this application must be identified with the name and
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address of the premises.
address of the premises.
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Contributor Agency Section:
Contributor Agency Section:
ORI: NY922217Z
ORI: NY922217Z
Agency Code: 700208L
Agency Code: 700208L
Contributor Agency: NYS Liquor Authority
Contributor Agency: NYS Liquor Authority
Applicant Section:
Applicant Section:
New Submission Resubmission
New Submission Resubmission
License Serial Number: ______________________________
License Serial Number: ______________________________
(obtain serial # from application receipt)
(obtain serial # from application receipt)
Name of Applicant:
Name of Applicant:
________________________________________________________________________
________________________________________________________________________
Alias / Maiden Name:
Alias / Maiden Name:
_________________________________________________________________ _ ______
_________________________________________________________________ _ ______
Street Address:
Street Address:
________________________________________________________________________
________________________________________________________________________
City, State, & Zip:
City, State, & Zip:
________________________________________________________________________
________________________________________________________________________
Date of Birth: _______________Age: _____ Sex: Male Female Race: ___________________
Date of Birth: _______________Age: _____ Sex: Male Female Race: ___________________
Ethnicity: Hispanic Non Hispanic Unknown Height: _______ft. _______in. Weight: _________lbs.
Ethnicity: Hispanic Non Hispanic Unknown Height: _______ft. _______in. Weight: _________lbs.
Skin Tone: ______________________
Skin Tone: ______________________
Eye Color: _________________
Eye Color: _________________
Hair Color: ___________________
Hair Color: ___________________
State / Country of Birth: _______________________________ Country of Citizenship: _____________________
State / Country of Birth: _______________________________ Country of Citizenship: _____________________
Accepted Forms of Identification Section:
Accepted Forms of Identification Section:
NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (see Column A):
NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (see Column A):
Column A ‐ Valid Photo Identification:
Column A ‐ Valid Photo Identification:
Column B ‐ Valid Supplementary Identification:
Column B ‐ Valid Supplementary Identification:
U.S. Passport (unexpired or expired)
U.S. Passport (unexpired or expired)
Voter registration card
Voter registration card
Permanent Resident Card
Permanent Resident Card
U.S. Military card or draft record
U.S. Military card or draft record
Alien Registration Receipt Card
Alien Registration Receipt Card
Military dependent’s ID card
Military dependent’s ID card
Unexpired Foreign Passport
Unexpired Foreign Passport
Coast Guard Merchant Mariner Card
Coast Guard Merchant Mariner Card
Driver’s License or Photo ID Card
Driver’s License or Photo ID Card
Native American Tribal Document
Native American Tribal Document
(issued by U.S. State or Territory)
(issued by U.S. State or Territory)
Canadian Driver’s License
Canadian Driver’s License
School or College ID Card (with photo)
School or College ID Card (with photo)
U.S. Social Security Card
U.S. Social Security Card
Unexpired Employment Authorization
Unexpired Employment Authorization
Original or certified copy of a Birth Certificate
Original or certified copy of a Birth Certificate
with photo (Form I‐766, I‐688, I‐688A or B)
with photo (Form I‐766, I‐688, I‐688A or B)
issued by authorized U.S. agency with official seal
issued by authorized U.S. agency with official seal
Photo ID Card issued by federal, state, or local govt.
Photo ID Card issued by federal, state, or local govt.
Certification of Birth Abroad (issued by U.S.
Certification of Birth Abroad (issued by U.S.
Department of State)
Department of State)
U.S. Citizen ID Card (Form I‐7)
U.S. Citizen ID Card (Form I‐7)