Form Dos 1496 – Fill Out and Use This PDF

NYS Department of State	BUREAU OF EDUCATIONAL STANDARDS
DIVISION OF LICENSING SERVICES	P.O. Box 22001
	Albany, NY 12201-2001

	SECURITY OR FIRE ALARM SYSTEM INSTALLER	Phone: (518)	486-3803
	QUALIFYING COURSE APPROVAL APPLICATION	Fax: (518)	408-2524
		www.dos.state.ny.us

PLEASE READ CAREFULLY, AS INCOMPLETE APPLICATIONS WILL BE RETURNED.

'All applications must be submitted 60 DAYS BEFORE the proposed course is to be conducted.

'No fee is required for this course approval.

'All instructors must be approved.

'Annual registration period runs from January 1st to December 31st.

1.MODULE COURSE APPROVAL REQUESTED

[] MODULE 1 - INSTALLATIONS: STANDARDS, CODES AND TECHNIQUES

[] MODULE 2 - CONTROL PANELS AND ALARM TRANSMISSIONS

[] MODULE 3 - SECURITY SYSTEMS

[] MODULE 4 - FIRE TECHNOLOGY

[] MODULE 5 - SERVICE AND MAINTENANCE OF ALARM SYSTEMS

2.EDUCATIONAL ORGANIZATION DATA

SCHOOL NAME

ADDRESS (NUMBER AND STREET; ROOM/SUITE DESIGNATION)

		CITY	STATE	ZIP+4
	COORDINATOR’S NAME (person authorized to submit application on behalf of entity and responsible for administering Department of State regulations)			TELEPHONE
	E-MAIL ADDRESS (if any)
				(	)
	HOME ADDRESS (NUMBER AND STREET)			TELEPHONE
				(	)
		CITY	STATE	ZIP+4
3.	PRIMARY COURSE LOCATION
	LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
		CITY	STATE	ZIP+4
4.	SECONDARY LOCATION
	LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
		CITY	STATE	ZIP+4
	LOCATION ADDRESS (PLACE, NUMBER AND STREET; ROOM/FLOOR/SUITE DESIGNATION)
		CITY	STATE	ZIP+4

Course Instructors: All instructors of approved courses must be approved with the Department of State. Applications for security or fire alarm installer instructor approval are available by request to the Division of Licensing Services, Bureau of Educational Standards

FOR OFFICE EFFECTIVE DATE: ____/____/____ EXPIRATION DATE: ____/____/____ ENTERED ____/____/____ BY: ________

USE ONLY

APPROVAL MAILED: ____/____/____

DOS-1496 (Rev. 1/09)

Security or Fire Alarm System Installer Qualifying Course Approval Application

Page 2 of 2

5.TYPE OF EDUCATIONAL ORGANIZATION OWNERSHIP

Is this organization an accredited College or University? Yes [ ] No* [ ] If No*, Please complete one of the following:

INDIVIDUAL: (Please submit a certified copy of the Trade Name Certificate and complete the following for Owner.)

NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4

PARTNERSHIP: (Please submit a copy of Partnership Agreement and complete the following for all Partners.)

NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4
NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4

CORPORATION: (Please submit a copy of the Certificate of Incorporation and complete the following for all officers and other individuals who own 5% or more of the stock of this corporation. If needed, attach additional sheets.)

NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4
NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4
NAME		HOME ADDRESS (NUMBER AND STREET)
	CITY	STATE	ZIP+4

6.Has any owner, partner, owner of 5% or more of the stock of the entity, or individual authorized to submit this application on behalf of the entity been convicted of any crime or offense, other than a minor traffic violation?

[ ] Yes* [ ] No

If Yes*, submit a certified copy of each conviction.

7.Has any license or permit issued to, applied for by any owner, partner, holder of 5% or more of the stock of the entity, or individual authorized to submit this application on behalf of the entity, been denied, suspended or revoked by this state or elsewhere by any other government or regulatory body?

[ ] Yes* [ ] No

If Yes*, please provide details.

8.COURSE CONTENT- ALL OF THE FOLLOWING MUST BE SUBMITTED:

[ ] a detailed course outline for each course with time sequence of each segment. (See section 196.9 for curriculum.)

[ ] the final examination to be presented for the course, including the answer key, reference page and source and subject matter category. [ ] a description of materials that will be distributed.

[ ] the books that will be utilized in the course and final examination.

[ ] a sample certificate of successful completion as described in Section 196.13. [ ] list of names and signatures of individuals authorized to sign certificates.

Correspondence Courses (see Sections 196.6 and 196.7):

[ ] in addition to the above, you must submit a complete description of the method in which the course will be presented. [ ] the complete lesson plan that will be issued to the student.

[ ] a complete description of the method as to how the final examination will be conducted.

I subscribe and affirm under the penalties of perjury that the statements made in this application (including statements made in any accompanying papers) have been examined by me, and to the best of my knowledge and belief, are true and correct.

I understand that any misstatement made on this application for approval could result in an immediate revocation or withdrawal of the recognition of the approval of the entity by the Department of State.

Coordinator Signature X

Date

DOS-1496 (Rev. 1/09)