Form Dos-1206-F-A - Employee Statement And Security Guard Application Page 2
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5Employee Statement and Security Guard Application
CHILD SUPPORT STATEMENT
By signing this application, I certify that as of the date of this application, I am not under an obligation to pay child support OR if I am
under an obligation to pay child support, I am not four or more months in arrears in the payment of child support, or I am making
payments by income execution or by court agreed payment or repayment plan or by a plan agreed to by the parties or my child support
obligation is the subject of a pending court proceeding, or I am receiving public assistance or supplemental security income.
CRIMINAL HISTORY
The Department of State will be receiving and reviewing information on any prior criminal arrests or convictions. If you have pending
criminal charges or a prior conviction, please provide a statement explaining same and copies of any records received from the criminal
court.
A completed application must include: (Use this checklist to make sure you have included/completed all requirements.)
The completed, signed application;
Receipt that provides proof of electronic fingerprinting by an approved vendor;
$36.00 non-refundable application fee payable to the NYS Department of State;
A copy of the 8-hour pre-assignment training certificate;
Any additional documentation requested in response to specific questions on the application form;
Notice of Employment section must be completed by your employer if employment will commence with filing of your
application;
If applying for an armed security guard registration, a course completion certificate for 47 hours of firearms training, or a copy
of the waiver issued by the Division of Criminal Justice Services (if waived – please see Security Guard Training Advisory)
Note: Security guard employers should maintain one copy of each item listed above in personnel files for each of their
guards.
APPLICANT AFFIRMATION
I affirm, under the penalties of perjury, that the statements made in this application are true and correct. I further affirm that I have read
and understand the provisions of Article 7A of the General Business Law and the rules and regulations promulgated thereunder.
In addition, I hereby authorize the NYS Department of State and NYS Department of Motor Vehicles to produce and ID card bearing my
DMV photo. I understand that DOS and DMV will use my DMV photo to produce all subsequent ID cards for as long as I maintain my
license with the Department of State.
x
Applicant’s Signature
Date Signed
Print Name:
NOTICE OF EMPLOYMENT
If employment will commence with the filing of your application, this section MUST be completed by your employer.
DATE OF HIRE:
TRANSACTION NUMBER:
TRANSACTION DATE:
GUARD’S NAME:
GUARD’S SOCIAL SECURITY NUMBER:
EMPLOYER’S UID:
EMPLOYER’S BUSINESS NAME:
I,
, swear and affirm that I am the representative for the company
(Please Print)
identified as the employer and that I have verified the statements made by this employee and determined that these statements are true
and correct to the best of my ability. I further attest that based on my verification of these statements, I find that the employee listed
hereon is qualified for employment under the provisions of Articles 7 and 7-A of the General Business Law.
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Employer’s Signature
Date Signed
DOS-1206-f-a (Rev. 09/16)
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