Instructions For Form Dcjs-4 - Non Criminal Fingerprint Card - Department Of Taxation And Finance

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New York State Department of Taxation and Finance
CG-100-F-I
Instructions for Form DCJS-4
(8/03)
Non Criminal Fingerprint Card
DO NOT FOLD OR BEND THE FINGERPRINT CARD.
General information
Who must complete a fingerprint card
Complete Form DCJS-4 (except for items 19, 26 and 29) before
taking it to your local police agency for fingerprinting. Fingerprints
Every controlling person, as defined on the back page, must
may be taken at your local police department, a sheriff’s
complete and submit Form DCJS-4, Non Criminal Fingerprint Card .
department or in some states, the state police. It is recommended
that you contact your police agency prior to your arrival, as many of
Item-by-item instructions
the local police agencies perform fingerprint services either during
very limited hours or by appointment only. In some jurisdictions, the
Item 1 - Leave blank
police agency will only perform this service for residents of the
jurisdiction.
Item 2 - Enter your legal name (Last, First, Middle).
When appearing before the local police agency to have your
Items 3, 3A and 4 - Enter your mailing address including ZIP code.
fingerprints taken, you must be able to prove your name, current
Item 5 - Leave blank
address, date of birth and signature. You should contact the police
agency ahead to inquire as to the proper identification
Item 6 - Intentionally omitted.
requirements. The proof must be the original or a certified copy
from the issuing agency. The following is a partial list of possible
Item 7 - See instructions on the back of Form DCJS-4.
forms of proof of identification that may be accepted by the police
agency:
Item 8 - Enter “M” for male or “F” for female.
Items 9, 10, 10A, and 10B - See instructions on the back of
Proof of name and date of birth
Form DCJS-4.
Photo Driver License/Non-Driver ID
Item 10C - Enter your weight in pounds.
US Passport
US Military Photo ID Card
Item 11 - Enter your height in feet and inches.
Foreign Passport - in English. If not in English, a certified
Item 12 - Enter your date of birth.
translation by the embassy or consulate of the issuing country
is required.
Item 12A - Enter your age as of the date that the fingerprints are
Certificate of Citizenship
taken.
Valid Employment Authorization Card
Item 13 - See instructions on the back of Form DCJS-4.
In addition to the above, a birth certificate issued and certified by a
Items 14 and 15 - Leave blank
Board of Health or Bureau of Vital Statistics in the US, its territories
or possessions, will also be accepted as proof of date of birth.
Item 16 - Enter the Federal Employer Identification Number (FEIN)
of the applicant for a cigarette agent, cigarette
Proof of address
agent/wholesaler, cigarette wholesale dealer, or
cigarette vending machine operator (VMO) license.
Current utility bill
Photo Driver License/Non-Driver ID
Item 17 - Enter your social security number.
Current bank statement/record
Item 18 - Leave blank
The police agency may impose a fee for taking your fingerprints
Item 19 - Enter the date fingerprints are taken.
and may have specific requirements as to how that fee must be
paid. You should inquire about the fee when you call for hours,
Item 20 - No entry required
appointment or ID requirements.
Item 21 - Check the box marked “LICENSE APPLICATION.”
The fingerprint card and money order may be mailed along with
Form CG-100-P, Personal Questionnaire, with the application for
Item 22 - Leave blank
license or by itself.
Item 23 - No entry required
However, an application for license cannot be processed until the
Item 23A - Leave blank
fingerprint card, money order, and other required documents are
received by the New York State Department of Taxation and
Item 24 - Enter the name and mailing address of the applicant for a
Finance.
cigarette license.
Once your fingerprints have been taken, you should mail the card
Item 25 - Leave blank
along with a money order in the amount of $75.00 payable to the
Division of Criminal Justice Services (DCJS) to:
Item 26 - You must sign the application in front of the person who
will be taking your fingerprints.
NYS TAX DEPARTMENT
TTTB - REGISTRATION AND BOND UNIT
Items 27 and 28 - Leave blank
W A HARRIMAN CAMPUS - WADE ROAD
ALBANY NY 12227
Item 29 - The signature of the person taking your fingerprints
is required.
(The DCJS will only accept money orders.)
Item 30 - See instructions on the back of Form DCJS-4.
DO NOT FOLD OR BEND THE FINGERPRINT CARD.

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