Security Guard Class Roster / Notification Of Successful Completion Form
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2DCJS 3222 (February 2016)
New York State Division of Criminal Justice Services
SECURITY GUARD PROGRAM – SECURITY GUARD CLASS ROSTER / NOTIFICATION OF SUCCESSFUL COMPLETION
THIS FORM IS USED TO SUBMIT NAMES OF PERSONS WHO SUCCESSFULLY COMPLETED SECURITY GUARD TRAINING
REQUIRED BY ARTICLE 7 OF THE GENERAL BUSINESS LAW §89-N. FORMS PRESENTED FOR FILING MUST CONTAIN
ORIGINAL SIGNATURES. ALTHOUGH THE BLANK FORM MAY BE DUPLICATED, PHOTOCOPIES OF COMPLETED FORMS, OR
FORMS WITH PHOTOCOPIED SIGNATURES WILL NOT BE ACCEPTED. OMMISSIONS OR LACK OF INFORMATION WILL STOP
THE PROCESS.
Within seven days of completion of the class, the form must be forwarded to the Division of Criminal Justice Services, Security
Guard Program. The number of individuals in any class cannot exceed 35.
SECTION I – SCHOOL INFORMATION
Type the information required for each box. The form cannot be processed if any of the information is missing. Record the school
identification number EXACTLY as provided. Incomplete rosters or erroneous forms will be returned.
SECTION II – AFFIRMATION
This section contains an affirmation regarding the accuracy of this form and course content. This section must be ink signed and dated.
ORIGINAL SIGNATURES ONLY.
SECTION III – CLASS LIST
Enter the names of only the students who successfully completed the training. All information must be typed in the areas
provided. It is mandatory to include each student’s telephone number with area code.
SECTION I – SCHOOL INFORMATION
(To be completed by school)
SCHOOL IDENTIFIER
YEAR TRAINED
School Name & Training Site Address (include room number)
Course Number and Title (check one only)
(700)
8 Hour Pre-Assignment Training Course for Security Guards
(701)
16 Hour On the Job Training Course for Security Guards
School Director
(703)
8 Hour Annual In-Service Training Course for Security Guards
Guards
(704)
8 Hour Annual Firearms Training Course for Armed Security
Course Date(s) and Time(s)
Date – Day 1 (mm/dd/yyyy):
Start Time:
am
pm
End Time:
am
pm
*Time includes meal break
Date – Day 2 (mm/dd/yyyy):
Start Time:
am
pm
End Time:
am
pm
*Time includes meal break
Date – Day 3 (mm/dd/yyyy):
Start Time:
am
pm
End Time:
am
pm
*Time includes meal break
Date – Day 4 (mm/dd/yyyy):
Start Time:
am
pm
End Time:
am
pm
*Time includes meal break
Date – Day 5 (mm/dd/yyyy):
Start Time:
am
pm
End Time:
am
pm
*Time includes meal break
Long Firearms Course Number and Title
Other Course Number and Title
(702)
(705)
47 Hour Firearms Training Course for Armed Security Guards
40 Hour Instructor Development Course
Course Date(s) (mm/dd/yyyy) From:
thru:
Instructor Name and Signature
Social Security Number
MAIL COMPLETED FORMS TO:
NYS Division of Criminal Justice Services
Office of Public Safety - Security Guard Program
rd
Alfred E. Smith State Office Building, 3
Floor
80 South Swan Street
.
Albany, New York 12210
QUESTIONS: (518) 457-4135
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