Fillable Form 16.34: Employee Statement and Security Guard Application (New York State)

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Form 16.34: Employee Statement and Security Guard Application (New York State)

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New York State
Department of State
Division of Licensing Services
P.O. Box 22052
Albany, NY 12201-2052
Customer Service: (518) 474-7569
www.dos.ny.gov
Employee Statement and Security Guard Application
Read
ALL instructions 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.
FINGERPRINT REQUIREMENTS: Applicants have access
to electronic fingerprinting through IdentoGo by IDEMIA.
Electronic Fingerprinting Procedure:
Schedule Appointment: Applicants must schedule
appointments with IdentoGo by IDEMIA. To schedule an
appointment at a location near you, visit their website at
www.identogo.com or call 877-472-6915. For scheduling
purposes, you must utilize the required Service Code 1545R1.
Failure to use the correct license type or Service Code may
result in the need to be reprinted.
What to bring to Appointment: Approved and
acceptable form of identification (for a list, please visit
www.dos.ny.gov/licensing/fingerprinting.html), along
with an acceptable form of payment.
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 your application.
The second copy of the receipt should be retained by
your employer.
Please Note: Fingerprint receipts are valid for 5 months
from the date of fingerprinting. Please submit original
application within 5 months from the date of fingerprinting.
Failure to submit your application within this time period
will require you to complete the fingerprint process again.
Fingerprint Fees:
All fees for fingerprinting are payable to IDEMIA.
● Division of Criminal Justice Services (DCJS) fee: $75.00
● FBI fee (Security Guard License applicants must pay
the FBI fee): $13.25.
● Applicable Fingerprint Vendor fee (subject to change in
January and July of each year)
See “e-Fingerprinting” link on top right at:
www.dos.ny.gov/licensing.
Acceptable forms of Payment:
Payment for fingerprint fees must be made in the form of
check, money order or credit card payable to IDEMIA.
Note: Fingerprinting fees are in addition to application fees.
Please read the below FBI Application Notifications:
● Fingerprints submitted will be used to check the criminal
history records of the FBI.
● Procedures for obtaining a copy of an FBI criminal
history record are set forth at Title 28, Code of Federal
Regulations (CFR), Sections 16.30 through 16.33 or go
to the FBI website at http://www.fbi.gov/about-
us/cjis/background-checks
● Procedures for obtaining a change, correction or
updating an FBI criminal history record are set forth at
Title 28, Code of Federal Regulations (CFR), Section
16.34
Child Support Statement
A Child Support Statement is mandatory in New York
State (General Obligations Law) 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.
SOCIAL SECURITY NUMBERS (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 other notifications pursuant to your
registration.
DOS-1206-f-a (Rev. 05/20)
Page 1 of 5
WOULD YOU LIKE TO REGISTER TO VOTE?
Please visit the NY State Board of Elections at www.elections.ny.gov/votingregister.html
or call 1-800-FOR-VOTE to request a NYS Voter Registration form.
To re
g
ister online
,
p
lease visit www.n
y
.
g
ov/services/re
g
ister-vote.
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:
Security Guard (unarmed)
Initial Training Requirements:
● 8 Hour Pre-Assignment Training – A general introductory course. You must complete this course and submit a copy of the
certificate issued to you with your security guard application. You are only required to take this course one time.
● 16 Hour On-The-Job Training (OJT) – A course 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 as a security guard.
Annual Training Requirement:
● 8 Hour Annual In-Service Training – This course must be completed each calendar year you hold a security guard registration.
Your registration is issued for two years, therefore, you must complete two 8 Hour Annual In-Service training courses within your
registration effective and expiration dates to be eligible for renewal.
Armed Security Guard
Initial Training Requirements:
● 8 Hour Pre-Assignment Training – 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 Training (OJT) – A course 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 as a security guard.
● 47 Hour Firearms Training – You must possess a valid NYS Pistol Permit and security guard registration to enroll in this course.
Upon successful completion of this course, submit a copy of the certificate with your application for an armed guard registration
upgrade.
Annual Training Requirements:
● 8 Hour Annual In-Service Training – This course must be completed each calendar year you hold an armed security guard
registration. Your registration is issued for two years, therefore, you must complete two 8 Hour Annual In-Service training courses
within your registration effective and expiration dates to be eligible for renewal; and
● 8 Hour Annual Firearms Training – This course must also be completed each calendar year you hold an armed security guard
registration. Your registration is issued for two years, therefore, you must complete two 8 Hour Annual Firearms training courses
within your registration effective and expiration dates to be eligible for renewal.
Peace Officer Waivers - Applications for a waiver of training for unarmed and armed security guards may be reviewed up to a
maximum of four years after separation from a non-exempt, sworn, full-time peace officer position in New York. IF YOU ARE A
SEPARATED POLICE OFFICER OR EXEMPT PEACE OFFICER, DO NOT SUBMIT A WAIVER APPLICATION, SEE
EXEMPTIONS BELOW. For the 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
courses. To request a waiver, contact DCJS directly at (518) 457-6726, or write them at 80 South Swan Street, 3rd Floor, Albany, NY
12210-8002. 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. However, if you are an active police officer,
anticipating retirement, and still wish to obtain a Security Guard Registration, you must provide proof of original police officer training
and a letter of good standing from the agency that employs you, along with the original Security Guard Application and finger print
receipt.
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.
DOS-1206-f-a (Rev. 05/20)
Page 2 of 5
Security Guard Training Advisory
Waivers/Exem
p
tions from Mandated Trainin
g
Security Guard Training Advisory Waivers/Exemptions from Mandated Training
II. Peace Officers:
Section 170.1 of Title 19 NYCRR e
xempts 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 Couse, and the addition 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 than 10 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 completed 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 Department 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.
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 basis course without firearms. In addition, if the individual is in an armed position, the individual
must have completed MPYC 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.
DOS-1206-f-a (Rev. 05/20) Page 3 of 5
FOR OFFICE USE ONLY CASH#:
UID: PREV. UID: CLASS: CODE:
New York State
Department of State
Division of Licensing Services
P.O. Box 22052
Albany, NY 12201-2052
Customer Service: (518) 474-7569
www.dos.ny.gov
Employee Statement and Security Guard Application FEE $36
APPLICANT INFORMATION
Please TYPE or PRINT all responses in ink.
APPLICATION AS (Check only ONE): Security Guard Armed Security Guard
Applicant’s Name:
LAST NAME
FIRST NAME MIDDLE NAME
HOME 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) APPLICANT’S PHONE NUMBER
E-MAIL ADDRESS
Social Security Number: Birth Date: NYS DMV ID Number:
(*Required – See Privacy Notification) (Must be at least 18 years old to apply) (*Required – See Applicant Affirmation)
BACKGROUND QUESTIONS
Answer the following questions by checking the appropriate box.
1. Are you an active or retired peace officer? IF “YES,” ACTIVE RETIRED
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.
2. Are you an active or retired police officer? IF “YES,”
ACTIVE RETIRED
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.
3. Has any license or permit issued to you or a company in which you are or were a principal
in New York State or elsewhere ever been revoked, suspended or denied? YES NO
IF “YES,” you must submit an explanation.
4. Have you ever been discharged from a correctional or law enforcement agency for
incompetence or misconduct as determined by a court of competent jurisdiction, administrative
hearing officer, administrative law judge, arbiter, arbitration panel or other duly constituted
tribunal, or resigned from such an agency while charged with misconduct or incompetence? YES NO
IF “YES,” you must submit an explanation or request a waiver.
5. Have you ever applied in this state for a registration/license as a security guard? YES NO
IF “YES,” please provide the license number.
IF “YES,” you do not need to re-take the 8-hour pre-assignment training course.
DOS-1206-f-a (Rev. 05/20) Page 4 of 5
Employee Statement and Security Guard Application
CHILD SUPPORT STATEMENT
By signing this application, I certify that as of the date of this application, I am not under an obligation to pay child support OR if I am
under an obligation to pay child support, I am not four or more months in arrears in the payment of child support, or I am making
payments by income execution or by court agreed payment or repayment plan or by a plan agreed to by the parties or my child support
obligation is the subject of a pending court proceeding, or I am receiving public assistance or supplemental security income.
CRIMINAL HISTORY
The Department of State will be receiving and reviewing information on any prior criminal arrests or convictions. If you have pending
criminal charges or a prior conviction, please provide a statement explaining same and copies of any records received from the criminal
court.
A completed application must include: (Use this checklist to make sure you have included/completed all requirements.)
The completed, signed application;
Receipt that provides proof of electronic fingerprinting by an approved vendor;
$36.00 non-refundable application fee payable to the NYS Department of State;
A copy of the 8-hour pre-assignment training certificate;
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 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.
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.
In addition, I hereby authorize the NYS Department of State and NYS Department of Motor Vehicles to produce an ID card bearing my
DMV photo. I understand that DOS and DMV will use my DMV photo to produce all subsequent ID cards for as long as I maintain my
license with the Department of State.
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
DOS-1206-f-a (Rev. 05/20) Page 5 of 5
Become an Organ and Tissue Donor
Organ donors save lives. If you would like to be an organ and tissue donor upon your death, you may enroll in the
NYS Donate Life Registry online at www.donatelife.ny.gov/register or complete the form below. Completed forms
should be sent to the NYS Donate Life Registry by email --- Registry@donatelife.ny.gov or, mail - NYS Donate Life
Registry, 185 Jordon Road, Troy, NY 12180.
Fields with an asterisk (*) are required for enrollment. Upon receipt of your completed enrollment form, you will be
sent an email or letter confirming your enrollment and providing you with information on how to limit your donation.
I understand that by opting out of enrolling in the NYS Donate Life Registry, or skipping this question, will not impact
or impair my ability to obtain services from the New York Department of State, Division of Licensing Services.
*Last name
*First name
Middle Initial Suffix
*Address
*Apt. Number *Zip Code
*City
*Birth date / / *Gender M
F
MM DD YYYY
Email address
DMV or IDNYC Number
By sign
ing below, you certify that you are:
• 16
years of age or
older;
• Consent
ing to donate your organs and tissues fo
r
transplant
ation and/or research in the event of your de
ath;
• Auth
orizing the New York Department of State, Division
of
Licen
sing Services to transfer your name and identifyin
g
information to the NYS Donate Life Registry for
enrollment;
and
• Authorizing the Registry to give access to this information
to federa
lly regulated organ procurement organization
s
and NYS-lice
nsed tissue and eye banks and others
approved by the NYS Commissioner of Health in
the event
of your death.
*Sign *Date
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Form 16.34: Employee Statement and Security Guard Application (New York State)

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Completed 6 April 2021

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