Request Form For Fingerprinting Services (Page 2 of 2) in pdf

Rev-02/05/16

Request 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. The current fee is $102.00.

REMINDERS

You will be notified after the submission of your application to schedule your electronic

fingerprinting through IdentoGo by MorphoTrust USA.

Everything submitted in support of this application must be identified with the name and

address of the premises.

Contributor Agency Section:

ORI: NY922217Z

Agency Code: 700208L

Contributor Agency: NYS Liquor Authority

Applicant Section:

New Submission

Resubmission

License Serial Number: ______________________________ Applicant SS #: ______________________________

(obtain serial # from application receipt)

Applicant Last Name:

____________________________First Name: __________________________________

Alias / Maiden Name:

____________________________Middle: _____________________________________

Street Address:

________________________________________________________________________

City, State, & Zip:

________________________________________________________________________

Date of Birth: _______________Age: _____

Sex:

Male

Female

Race: ___________________

Ethnicity:

Hispanic

Non Hispanic

Unknown

Height: _______ft. _______in. Weight: _________lbs.

Skin Tone: ______________________

Eye Color: _________________

Hair Color: ___________________

State / Country of Birth: _______________________________ Country of Citizenship: _____________________

Accepted Forms 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 - Valid Photo Identification:

Column B - 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, I-688, I-688A or B)

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)

Request Form For Fingerprinting Services Page 2

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