EMPLOYEE STATEMENT AND SECURITY GUARD APPLICATION

APPLICANT INFORMATION

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

APPLICANT’S PHONE NUMBER

Social Security Number:

(*Required – See Privacy Notification)

Birth Date:

(Must be at least 18 years old to apply)

NYS DMV ID Number:

(*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,”

→ 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.

Are you an active or retired peace officer?

ACTIVE

RETIRED

2. Are you an active or retired police officer? 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.

Are you an active or retired police officer?

ACTIVE

RETIRED

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license or permit issued to you or a company in which you are or were a principal in New York State or elsewhere ever been revoked, suspended or denied?

→ IF “YES,” you must submit an explanation.

Has any license or permit issued to you

YES

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?

→ IF “YES,” you must submit an explanation or request a waiver.

Have you ever been discharged from a correctional

YES

5. Have you ever applied in this state for a registration/license as a security guard?

→ IF “YES,” please provide the license number

→ IF “YES,” you do not need to re-take the 8-hour pre-assignment training course.

Have you ever applied in this state for a registration/license as a security guard?

YES

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.)

Checklist

The completed

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 of the waiver issued by the Division of Criminal Justice Services (if waived – please see Security Guard Training Advisory);

Statement explaining circumstances surrounding any prior convictions

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.

Applicant’s Signature

Print Name:

Print Name

Date Signed

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.

Print Name

Employer’s Signature

Date Signed

Thanks for submitting!