Form Dos1206 – Fill Out and Use This PDF

FOR OFFICE USE ONLY		CASH#:					FEE: $36
UID:		PREV. UID:			CLASS:		CODE:

INSTRUCTIONS: Forms must be completed in blue or black ink. Incomplete forms will not be processed. Please refer to pages 5 and 6 for further instructions on completing this form.

APPLICANT INFORMATION SECTION

APPLICATION AS (Check only ONE):

Security Guard

Armed Security Guard

Social Security Number:

-

-

Birth Date:

-

-

(Must be at least

(See Instructions-Privacy Notification)

18 years old to apply.)

M

M

D D

Y

Y Y Y

Applicant's Name: LAST NAME

FIRST NAME

MIDDLE NAME

NAME SUFFIX (For example: Sr. / Jr. / III )

Gender:

Race:

Male

Female

White

Black

American Indian or Alaskan Native

Asian or Pacific Islander

Other

Unknown

RESIDENCE ADDRESS

STREET ADDRESS (Required - P.O.Box may be added to ensure delivery)

APT/UNIT/PO BOX

CITY

STATE

ZIP+4

COUNTY (Enter only if in New York State)

COUNTRY/NATION (Of above address)

DAYTIME PHONE (INCLUDING AREA CODE)

FAX NUMBER - IF ANY (INCLUDING AREA CODE)

E-MAIL ADDRESS (IF ANY)

DMV Consent Section - IMPORTANT INFORMATION Regarding Your Photo ID

The Department of State produces photo ID cards in cooperation with the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver License or Non-Driver ID card, please provide your 9-digit DMV ID Number in the space provided below. Then read the informed consent and sign this form. If you do not have a current NYS photo Driver License or Non-Driver ID card, please have your photo taken at any nearby DMV office BEFORE you complete this application. For more details, refer to our notice, “Request for Photo ID.”

INFORMED CONSENT: I authorize the NYS Department of State and the NYS Department of Motor Vehicles (DMV) to produce an ID card bearing my DMV photo. I understand that DMV will send this card to the address I maintain with the Department of State. I also understand that the Department of State and DMV will use my DMV photo to produce all my subsequent ID Cards for as long as I maintain my license/ registration with the Department of State.

DMV ID#	-	-

X

Applicant's Signature

Date Signed

DOS1206 (Rev. 04/09)

Page 1 of 9

Employee Statement and Security Guard Application

BACKGROUND QUESTIONS

	3. Are you a retired police officer?	YES	NO
	➔ IF “YES,” please read the attached Security Guard Training Advisory.
	➔ IF you qualify for an exemption, you must submit the documentation described in the Advisory. If you DO NOT
	qualify, you must submit training certificates.
	4. Have you ever been convicted in this state or elsewhere of a crime or offense that is a misdemeanor or a felony?	YES	NO
	➔ IF “YES,” you must submit with this application a written explanation giving the place, court jurisdiction, nature of the
	offense,sentence and/or other disposition. You must submit a copy of the accusatory instrument (e.g., indictment, criminal
	information or complaint) and a Certificate of Disposition. If you possess or have received a Certificate of Relief from
	Disabilities, Certificate of Good Conduct or Executive Pardon, you must submit a copy with this application.

DOS1206 (Rev. 04/09)

Page 2 of 9

Employee Statement and Security Guard Application

EMPLOYMENT HISTORY

*Please enter the complete record of your occupation during the last five years. You may copy this page and attach as many sheets as needed.

Company One Information:

NAME OF COMPANY					EMPLOYMENT STATUS (Full-Time OR Part-Time)					HOURS PER WEEK WORKED
COMPANY ADDRESS
BUSINESS TELEPHONE		SUPERVISOR					DATES OF EMPLOYMENT (From –To)
POSITION				DUTIES

Company Two Information:

NAME OF COMPANY					EMPLOYMENT STATUS (Full-Time OR Part-Time)					HOURS PER WEEK WORKED
COMPANY ADDRESS
BUSINESS TELEPHONE		SUPERVISOR					DATES OF EMPLOYMENT (From –To)
POSITION				DUTIES

Company Three Information:

NAME OF COMPANY					EMPLOYMENT STATUS (Full-Time OR Part-Time)					HOURS PER WEEK WORKED
COMPANY ADDRESS
BUSINESS TELEPHONE		SUPERVISOR					DATES OF EMPLOYMENT (From –To)
POSITION				DUTIES

Company Four Information:

NAME OF COMPANY

EMPLOYMENT STATUS (Full-Time OR Part-Time)

HOURS PER WEEK WORKED

COMPANY ADDRESS

BUSINESS TELEPHONE

SUPERVISOR

DATES OF EMPLOYMENT (From –To)

POSITION

DUTIES

DOS1206 (Rev. 04/09)

Page 3 of 9

Employee Statement and Security Guard Application

CHILD SUPPORT STATEMENT

You MUST complete this section. If you do not complete it, your application will NOT be processed.

I, the undersigned, do hereby certify that (You must “X” A or B, below):

A.	I am not under obligation to pay child support. (SKIP “B” and go directly to Applicant Affirmation).
B.	I am under obligation to pay child support (You must “X” any of the four statements below that are true and apply to you):
	I do not owe four or more months of child support payments.
	I am making child support payments by income execution or court approved payment plan or by a plan agreed to by the parties.
	My child support obligation is the subject of a pending court proceeding.
	I receive public assistance or supplemental social security income.

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.

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, (Please Print), swear and affirm that I am the representative for the company 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.

X

Employer's Signature

Date Signed

DOS1206 (Rev. 04/09)

Page 4 of 9

Employee Statement and Security Guard Application

INSTRUCTIONS

Read ALL instructions in this package carefully before completing the application. Incomplete forms will be returned. Any omission, inaccuracy or failure to make full disclosure may be deemed sufficient reason to deny a registration or may result in the suspension or revocation of an issued registration.

A COMPLETED APPLICATION MUST INCLUDE: (Use this checklist to make sure you have included/completed all requirements.)

□The completed, signed application;

□Original certificate showing completion of an 8-hour pre-assignment course;

□Signed DMV Informed Consent;

□Receipt that provides proof of electronic fingerprinting by an approved vendor and the Request for NYS Fingerprinting Services Information Form (DCJS Rev. 11 - 03/04/09) OR

□Rolled FBI (blue) fingerprint card and NYS Request for Card Scan Information Form (DCJS Rev. 11 - 03/04/09);

□$36.00 application fee payable to the NYS Department of State. See “Application Requirements -acceptable forms of payment;”

□Applicable fingerprint fees payable to L-1 Enrollment Services. See “Fingerprint Requirements-acceptable forms of payment;”

□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 enclosed 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.

APPLICATION REQUIREMENTS:

Duties of a Security Guard:

A security guard, as defined in Article 7A of the General Business Law [§89-f(6)], is a person employed in New York State to principally perform one or more of the following functions for the: (a) protection of individuals and/or property from harm, theft or other unlawful activity; (b) deterrence, observation, detection and/or reporting of incidents in order to prevent any unlawful or unauthorized activity including but not limited to unlawful or unauthorized intrusion or entry, larceny, vandalism, abuse, arson or trespass on property; (c) street patrol service; or (d) response to but not installation or service of a security alarm system alarm installed and/or used to prevent or detect unauthorized intrusion, robbery, burglary, theft, pilferage and other losses and/or to maintain security of protected premises.

Required Training:

All security guards (except for those waived or exempted) are required to complete training programs conducted at approved training schools by certified instructors. (PLEASE SEE THE ATTACHED SECURITY GUARD TRAINING ADVISORY TO FIND OUT IF YOU QUALIFY TO BE WAIVED OR EXEMPTED. If you qualify, submit the documentation described in the Advisory. If you do not qualify, submit training certificates.)

Training programs include:

•8-hour Pre-Assignment — a general, introductory course. Must submit proof of successful completion.

•16-hour On-the-Job Training (OJT) — relevant to the duties of guards, requirements of the work site and the needs of the employer. Must successfully complete this training within 90 days of employment.

•8-hour Annual In-Service Training — must complete within one calendar year of completion of the 16-hour OJT course, and every year thereafter.

In addition to the above courses, security guards who carry a firearm must also complete:

•47-hour Firearms Course — Must successfully complete training and submit certificate with your application for issuance of an armed guard registration card.

•8-hour Annual Firearms Course — must complete within one calendar year of completion of the 47-hour firearms course, and every year thereafter.

Fee and term of registration:

The non-refundable application fee for a security guard registration is $36.00 payable to the NYS Department of State. The renewal fee is $25.00, every two years.

Acceptable forms of payment:

You may pay by Money Order, Company Check or Cashier's Check made payable to the NYS Department of State. Personal checks or credit cards will not be accepted. Do not mail cash.

DOS1206 (Rev. 04/09)

Page 5 of 9