Form Dos-1206-F-A - Employee Statement And Security Guard Application
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1
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5FOR OFFICE USE ONLY
CASH#:
UID:
PREV. UID:
CLASS:
CODE:
New York State
Department of State
Division of Licensing Services
P.O. Box 22052
Albany, NY 12201-2052
Customer Service: (518) 474-7569
Employee Statement and Security Guard Application
FEE $36
APPLICANT INFORMATION
Please TYPE or PRINT all responses in ink.
APPLICATION AS
(Check only ONE):
Security Guard
Armed Security Guard
Applicant’s Name:
LAST NAME
FIRST NAME
MIDDLE NAME
HOME ADDRESS (Required – P.O. Box may be added to ensure delivery)
APT/UNIT/PO BOX
CITY
STATE
ZIP+4
COUNTY (Enter only if in New York State)
APPLICANT’S PHONE NUMBER
E-MAIL ADDRESS
NYS DMV ID Number:
Social Security Number:
Birth Date:
(*Required – See Privacy Notification)
(Must be at least 18 years old to apply)
BACKGROUND QUESTIONS
Answer the following questions by checking the appropriate box.
1. Are you an active or retired peace officer? IF “YES,”
ACTIVE
RETIRED
Please read the attached Security Guard Training Advisory.
IF you qualify for an exemption, you must submit the documentation described in the Advisory.
If you DO NOT qualify, you must submit training certificates.
2. Are you an active or retired police officer? IF “YES,”
ACTIVE
RETIRED
Please read the attached Security Guard Training Advisory.
IF you qualify for an exemption, you must submit the documentation described in the Advisory.
If you DO NOT qualify, you must submit training certificates.
3. Are you a citizen of the United States or a resident alien of the United States in possession
of a valid alien registration card?
YES
NO
IF “NO,” you must submit an explanation
4. Has any license or permit issued to you or a company in which you are or were a principal
in New York State or elsewhere ever been revoked, suspended or denied?
YES
NO
IF “YES,” you must submit an explanation.
5. Have you ever been discharged from a correctional or law enforcement agency for
incompetence or misconduct as determined by a court of competent jurisdiction, administrative
hearing officer, administrative law judge, arbiter, arbitration panel or other duly constituted
tribunal, or resigned from such an agency while charged with misconduct or incompetence?
YES
NO
IF “YES,” you must submit an explanation or request a waiver.
6. Have you ever applied in this state for a registration/license as a security guard?
YES
NO
IF “YES,” please provide the license number.
IF “YES,” you do not need to re-take the 8-hour pre-assignment training course.
DOS-1206-f-a (Rev. 09/16)
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