New York State
Department of State
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
Customer Service: (518) 474-4429
www.dos.ny.gov
Request for Certification/Certified Copies of Records
PLEASE FILL IN ALL OF THE INFORMATION REQUESTED:
Your Name: Your Phone Number:
( )
Your Current Address:
Mail Certification To
:
□
Check box if
same as above.
Type of License
to be
Searched:
Name You
Want Searched:
Previous Name
(if applicable):
Unique Identification
Number:
NOTE: The Division of Licensing Services maintains a six year file of licensees. Records prior to that time
period are unavailable.
$25 fee per record:
If the requested document is for another state, please provide the name of the state: ________________________________________
If multiple copies are needed for multiple states, please list each state and submit $25 for each copy requested.
□ CERTIFICATION
□ CERTIFIED LICENSE HISTORY
□ CERTIFIED COPIES OF APPLICATIONS
Please submit this request
to our office at the above address with a check or money order made payable to NYS Department of State.
You may also pay by MasterCard or Visa, using the appropriate credit card authorization form.
REQUESTS RECEIVED WITHOUT PAYMENT WILL BE
RETURNED
DOS-0999-f (Rev.01/16)
