Form Ocfs-4930 - Request For Nys Fingerprinting Services - Nys Office Of Children And Family Services
ADVERTISEMENT
1
2OCFS-4930 (06/26/2017) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
REQUEST FOR NYS FINGERPRINTING SERVICES
Child Day Care Programs
Enrollment Information:
Applicant must have an appointment to be fingerprinted. At the appointment, the applicant will need to bring this form and
acceptable ID.
Appointments can be made by contacting the vendor at one of the following:
Website:
or the Call Center: 877-472-6915
Contributor Agency Section:
15441V
Service Code:
Contributor Agency:
NYS Office of Children and Family Services-Child Day Care Programs
Facility/Agency ID Number:
Facility Name/Address:
Fingerprint Applicant Section:
New Submission
Resubmission
Name of Applicant:
Alias / Maiden Name:
Street
Address:
City, State, & Zip:
Date of Birth:
/
/
Sex:
Male
Female
Other
Ethnicity:
Hispanic
Non-Hispanic
Race:
White
Black
American Indian/Alaskan Native
Asian/Pacific Islander
Other
Unknown
Skin Tone:
Eye Color:
Hair Color:
Height:
ft
in
Weight:
lbs.
State/Country
of Birth:
Role of Fingerprint Applicant (please check one):
CHILD DAY CARE:
Director (D)
Provider (F)
Employee/Teacher (T)
Volunteer (V)
Household Member over the age of 18 (HM)
Fingerprint Applicant Affirmation Section
I hereby affirm that the information contained in the application and the supporting documents are true and do not contain any
false statements or omissions of any material information or facts. I understand that the making of false written statements in this
application is punishable as a class A misdemeanor under Section 175.30 and/or Section 210.45 of the New York Penal Law.
Applicant Signature:
Date:
X
/
/
Payment Section:
Agency Billing Account
ADVERTISEMENT
0 votes
Related Articles
Related forms
Ocfs-ldss-4433 - Medical Statement Of Child In Childcare - New York State Office Of Children And Family Services
Legal
Verbal Medication Consent Form And Log Of Administration - New York State Office Of Children And Family Services
Legal
New York State Office Of Children And Family Services Month: Year: Child Care Attendance Sheet
Business
Related Categories
Parent category: Legal