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

Employee Statement and Security Guard Application

FINGERPRINT REQUIREMENTS:

Beginning April 1, 2009, applicants will have access to electronic fingerprinting through L-1 Enrollment Services. The Department of State will continue to accept rolled fingerprint cards through December 31, 2009.

Electronic Fingerprinting Procedure:

Schedule Appointment: Beginning March 27, 2009, applicants may begin scheduling appointments with L-1 Enrollment Services for an appointment date of April 1st or later. To schedule an appointment at a location near you, visit their website at www.L1enrollment.com or call 877-472-6915.

What to bring to Appointment: Complete the request for NYS Fingerprinting Services - Information Form (pdf) and BRING it with you to the fingerprinting site.

Proof of electronic fingerprint completion: Upon completion of the fingerprint process, the vendor will provide you with two receipts as proof of fingerprint completion. Include one receipt with the completed application. The second copy of the receipt should be retained by your employer.

Rolled Fingerprint Card (Acceptable through December 31, 2009):

If an electronic fingerprint location does not exist near your residence or place of business and it is not possible to travel to an available site, you may submit a rolled FBI (blue) fingerprint card with your application along with the NYS Request for Card Scan Services - Information form.

Fingerprint fees:

All fees for fingerprinting (including electronic and rolled fingerprint card methods ) are payable to L-1 Enrollment Services.

•Division of Criminal Justice Services (DCJS) fee: $75.00

•FBI fee (Security Guard License applicants must pay the FBI fee): $19.25

•Fingerprint Vendor fee: $11.50

Acceptable forms of payment:

Payment for fingerprint fees must be made in the form of check, money order or credit card payable to L-1 Enrollment Services.

NOTE: fingerprint fees are in addition to application fees.

ADDITIONAL REQUIREMENTS:

Notice of Employment:

Upon employment, employer must complete “Notice of Employment” section found in application. An individual does not have to be employed to be registered. Employers must determine the qualifications of each applicant for employment as a security guard. The employer must exercise minimum due diligence steps; specific steps are set forth in the Department of State rules, 19 NYCRR §174.6.

Child Support Statement:

A Child Support Statement is mandatory in New York State (General Obligations Law). The law requires you to complete this section — regardless of whether or not you have children or any support obligation.

Any person who is four months or more in arrears in child support may be subject to having his or her business, professional and driver’s licenses suspended. The intentional submission of a false written statement for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under §175.35 of the Penal Law. It is a class E felony to offer a false instrument for filing with a state or local government with the intent to defraud.

PRIVACY NOTIFICATION:

The Department of State is required to collect the federal Social Security and Employer Identification numbers of all licensees. The authority to request and maintain such personal information is found in §5 of the Tax Law and §3-503 of the General Obligations Law. Disclosure by you is mandatory. The information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or may have underestimated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. It will be used for tax administration purposes and any other purpose authorized by the Tax Law and may also be used by child support enforcement agencies or their authorized representatives of this or other states established pursuant to Title IV-D of the Social Security Act, to establish, modify or enforce an order of support, but will not be available to the public. A written explanation is required where no number is provided. This information will be maintained in the Licensing Information System by the Director of Administration and Management, at One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231-0001.

Section 89H of Article 7A requires that you notify this division of any changes to your residence address so you can receive renewal notices and any other notifications pertinent to your registration.

DOS1206 (Rev. 04/09)

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TRAINING REQUIREMENTS

Section 89-G of Article 7A requires all persons engaged in security guard activities be registered with the New York State Department of State (DOS), and complete all training (unless exempt) at schools approved by the Division of Criminal Justice Services (DCJS). The following training courses are required:

●8 Hour Pre-Assignment - A general introductory course. You must complete this course and submit a copy of the certificate issued to you with your security guard application.

●16 Hour On-The-Job (OJT) - Relevant to the duties of guards, requirements of the work site, and the needs of the employer. You must complete this training within 90 days of employment.

●8 Hour Annual In-Service - Must be completed in the calendar year following completion of the 16-hour OJT course, and every year thereafter.

Waivers - Applications for a waiver of the aforementioned security guard training may be reviewed up to a maximum of ten years after separation from a sworn law enforcement position in New York.

PLEASE SEE ATTACHED LIST OF EXEMPTIONS - THEY DO NOT REQUIRE A WAIVER

In addition to the above courses, security guards who carry a firearm must have their registration upgraded to Armed Guard status, and in order to do so must also complete:

●47 Hour Firearms Course - You must successfully complete this training at an approved school and submit a copy of the certificate with your application for issuance of an armed guard registration; and

●8 Hour Annual Firearms Course - Armed Guards must complete this course in the calendar year following the completion of the 47 Hour Firearms course and every year thereafter.

Waivers – Applications for a waiver of firearms training for Armed Guards may be reviewed up to a maximum of ten years after separation from a sworn law enforcement position in New York.

PLEASE SEE ATTACHED LIST OF EXEMPTIONS - THEY DO NOT REQUIRE A WAIVER

For purposes of registration, you may be granted a waiver from training if you can demonstrate completion of training that meets or exceeds the minimum standards for the 8-Hour Pre-Assignment, OJT, or 47 Hour Firearms course. Requests for waivers should be directed to DCJS. To request a waiver, contact DCJS directly at (518) 457-4135, or write them at 4 Tower Place, Albany, NY 12203. If approved, DCJS will send you a waiver letter to submit with your security guard application to DOS.

EXEMPTIONS (DO NOT REQUIRE A WAIVER FROM DCJS)

I. Police Officers:

The Security Guard Act exempts active police officers from the definition of a security guard. This means active police officers accepting secondary employment are not required to register or complete training.

Retired Police Officers:

In order to be exempt from the training, you must provide DOS with a letter from your department (signed by your department) indicating your retirement date. In addition, if you are required by your security guard employer to carry a firearm, or are authorized to have access to a firearm, you must provide proof to DOS and your employer of having completed a Basic Course for Police Officers (or an equivalent course), that included initial firearms training, within one year prior to employment as an armed security guard.

If your initial firearms training occurred more than a year before employment as an armed security guard, you must complete an 8 Hour Annual Firearms Course for Security Guards and report that training to DOS and your employer.

•If it has been more than 10 years since you retired as a police officer, you are additionally required to complete the 8 Hour Annual In- Service Training Course for Security Guards every year thereafter.

DOS1206 (Rev. 04/09) / Security Guard Training Advisory (Rev. 01/08)

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Security Guard Training Advisory Waivers/Exemptions from Mandated Training

II. Peace Officers:

Section 170.1 of Title 19 NYCRR exempts from the definition of a security guard, any individual designated as a peace officer under Article 2 of the NYS Criminal Procedure Law (CPL). The powers of a peace officer are only valid while the individual is acting in his or her official capacity for their primary employer. Consequently, during outside employment (moonlighting), a peace officer is no longer acting in his or her official capacity, and, therefore, must register and complete all training, (unless the individual has either been waived, or is exempt [based on specific job titles] (see Recent Amendments that may have a direct affect on you, below).

Current Peace Officers Applying for Firearms Training Waivers

If your employer has authorized you to carry a firearm in the line of duty, and you have been employed for 18 months or more and can exhibit a valid certificate, you are exempt from the 47 Hour Firearms Course, and the additional 8 Hour Annual Firearms Course for holders of an armed security guard registration. Individuals seeking registration as an armed guard, must provide the Department of State with a copy of a waiver letter (issued by DCJS) and a certificate of completion for the MPTC Basic Course for Peace Officer with Firearms, or both the Basic Course for Peace Officers without Firearms and Firearms and Deadly Physical Force [long firearms course].

Recent Amendments that may have a direct affect on you:

Section 89-n (4) GBL has been amended to exempt certain categories of peace officers (see Categories of Peace Officers Exempt from Training per Amendment to §89-n (4) GBL, next page) from the following training: 47 Hour Firearms Course, 8-Hour Pre- Assignment, OJT, and 8 Hour Annual In-Service. To qualify for an exemption, a peace officer must either be currently employed in one of the job titles (see Categories of Peace Officers Exempt from Training per Amendment to §89-n (4) GBL, next page), or retired from one of those job titles for NOT more than10 years. Although exempt from the 8 Hour Annual In-Service training course for the first 10 years of retirement, the retired peace officer is subject to an 8 Hour Annual Firearms training course, if their basic course was completed more than a year prior to filing their security guard application.

NOTE: If it has been more than 10 years since an individual retired as a peace officer, they are required to complete the 8 Hour Annual In-Service Training Course for Security Guards, and additionally, if armed, the 8 Hour Annual In-Service Firearms Training Course every year thereafter.

Categories of Peace Officers Exempt from Training per Amendment to §89-n (4) GBL

A. Sheriffs, Undersheriffs, and Deputy Sheriffs of NYC, and sworn officers of the Westchester County Dept. of Public Safety Services as defined in NYS CPL, §2.10 (2): In order to be exempt from the 47 Hour Firearms Training Course, 8-Hour Pre- Assignment, OJT, and Annual In-Service Training, individuals must provide the Department of State with either a copy of their Basic Course for Peace Officers certificate, or a letter from the personnel office of the entity for which they work(ed), indicating basic peace officer training. If currently employed, they must also provide a copy of their ID card showing current employment in one of the appropriate law enforcement categories, and that they are in good standing.

B.Security personnel for the Triborough Bridge and Tunnel Authority as defined in NYS CPL, §2.10 (20): In order to be exempt from the 47 Hour Firearms Training Course, 8-Hour Pre-Assignment, OJT, and Annual In-Service Training, individuals must provide the Department of State with either a copy of their Basic Course for Peace Officers certificate, or a letter from the personnel office of the entity for which they work(ed), indicating basic peace officer training. If currently employed, they must also provide a copy of their ID card showing current employment in one of the appropriate law enforcement categories, and that they are in good standing.

C.Uniformed Court Officer as defined in NYS CPL, §2.10 (21)(a): In order to be exempt from the 47 Hour Firearms Training Course, 8-Hour Pre-Assignment, OJT, and Annual In-Service Training, individuals must provide the Department of State with either a copy of their Basic Course for Peace Officers certificate, or a letter from the academy indicating their academy training. These courses must meet or exceed the MPTC basic course without firearms. In addition, if the individual is in an armed position, the individual must have completed MPTC Basic Course for Peace Officer with Firearms, or both the Basic Course for Peace Officers without Firearms and Firearms and Deadly Physical Force [long firearms course]. If currently employed, the individual must also provide a copy of their ID card showing current employment, and that they are in good standing.

DOS1206 (Rev. 04/09)

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Security Guard Training Advisory Waivers/Exemptions from Mandated Training

D. Court Clerks as defined in NYS CPL, § 2.10 (21)(b): In order to be exempt from the 47 Hour Firearms Training Course, 8-Hour Pre- Assignment, OJT, and Annual In-Service Training, individuals must provide the Department of State with either a copy of their Basic Course for Peace Officers certificate, or a letter from the academy indicating their academy training. These courses must meet or exceed the MPTC basic course without firearms. In addition, if the individual is in an armed position, the individual must have completed MPTC Basic Course for Peace Officer with Firearms, or both the Basic Course for Peace Officers without Firearms and Firearms and Deadly Physical Force [long firearms course]. If currently employed, the individual must also provide a copy of their ID card showing current employment, and that they are in good standing.

E. NYS Corrections Officers as defined in NYS CPL, §2.10 (25): (This does not include city or county correction officers) In order to be exempt from the 47 Hour Firearms Training Course, 8-Hour Pre-Assignment, OJT, and Annual In-Service Training, individuals must provide the Department of State with a letter from the NYS Department of Correctional Services and a copy of their ID card showing that they are currently employed as a NYS Corrections officer in good standing.

NOTE: Individuals who are no longer active peace officers and do not have a valid basic course certificate, or do not qualify for either a waiver or an exemption, must complete the 47 Hour Firearms Training Course, 8-Hour Pre-Assignment, and OJT.

DOS1206 (Rev. 04/09)

Page 9 of 9