Form Dos1870-F-L-A - Request For Nys Fingerprinting Services - Information Form
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1Request for NYS Fingerprinting Services - Information Form
Instructions for applicant: Complete this form and visit
or call 877-472-6915
to schedule an appointment for fingerprinting. Remember to bring this form and required forms of
identification to your fingerprinting appointment.
Contributor Agency Section:
ORI: SecGuard
Contributor Agency: NYS Department of State/LIC DIV
Security Guard
Job or License Type:
Agency ID Number:
(If assigned by contributor)
Applicant Section:
New Submission
Resubmission
Name of Applicant:
Alias / Maiden Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Age:
ft.
in.
Height:
Weight:
lbs.
Sex:
Eye Color:
Hair Color:
Race:
Ethnicity:
Skin Tone:
State / Country of Birth:
Country of Citizenship:
Alien Registration No.:
Misc. No.:
Required for Pistol Permits if not US Citizen
Billing Account Number (If applicable)
Accepted Form of Identification Section:
NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (See Column A):
Column A
Column B
- Valid Photo Identification:
- Valid Supplementary Identification:
U.S. Passport (unexpired or expired)
Voter registration card
►
►
Permanent Resident Card
U.S. Military card or draft record
►
►
Alien Registration Receipt Card
Military dependent's ID card
►
►
Unexpired Foreign Passport
Coast Guard Merchant Mariner Card
►
►
Driver’s License or Photo ID Card
Native American Tribal Document
►
►
(issued by U.S. State or Territory)
Canadian Driver's License
►
School or College ID Card (with photo)
U.S. Social Security Card
►
►
Unexpired Employment Authorization
Original or certified copy of a Birth Certificate
►
►
with photo (Form I-766)
issued by authorized U.S. agency with official seal
Photo ID Card issued by federal, state, or local govt.
Certification of Birth Abroad (issued by U.S.
►
►
Department of State)
U.S. Citizen ID Card (Form I-197)
►
Please Note: Applicants must be 18 years of age to be fingerprinted for a Security Guard Registration.
DCJS (Rev. 11 - 03/04/09)
DOS1870-f-l-a (Rev. 06/13)
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