SEE INSTRUCTIONS ON BACK
SECURITY GUARD RENEWAL
PRINT ANY CHANGES IN INK IN THIS AREA
YOUR NEW LAST NAME FIRST NAME Ml SUFFIX
Unique ID Number
$25.00
Fee Due
NEW HOME STREET ADDRESS (NUMBER STREET)
NEW HOME STREET CONTINUED
Current Term Expires: NEW HOME CITY STATE ZIP CODE+ 4 CNTY
1) Yes 0 No [i Since your last application, have you been convicted of a crime or offense (not minor traffic violation), in this state or elsewhere?
(If Yes, please enclose court disposition.)
i-7
2) Yes LJ No f Since your last application has any license, permit, commission, registration or application for a license, permit, commission
or registration held by or submitted by you or a company in which you are or were a principal been revoked. suspended, or
denied by any state, territory or governmental jurisdiction or foreign country for any reason? (If Yes, enclose details).
3) Yes [1 No [i Are there any criminal charges (misdemeanor or felony) pending against you in any court in this state or elsewhere? (If Yes,
you must submit a copy of the accusatory instrument e.g. indictment, criminal information or complaint).
Notice:
Prier to renewal you must complete mandatory training (see instructions on reverse side of form.) Our records show the following training is currently on flJe:
OJT:
Annual Training:
Annual Training:
OJT training is required of any guard employed for more than 90 days. If any of the above dates for annual training are missing, you must
complete that training prior to submission of your renewal form.
Child Support Statement:
By signing this application. I certify that as of the d ate 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 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 I am receiving public assistance or supplemental security income.
Applicant Affirmation:
I affirm. under the penalities of perjury. that the statements made in this application are true and correct.
In addition. I hereby autl1orize the t�YS Department of State and NYS Department of Motor Vehicles to produce an 1D card bearing my OMV photo.
understand that DOS and DMV will use my DMV phto to produce all subsequent ID Cards for as long as I maintain my license with the Department of
State.
Applicant Signature Date
Complete For Credit Card Payment Applicant's Unique ID Number: __..-�
Total amount due: $ ________
□
Applicant's Name:
Please charge to the following credit card:
□ Master Card Visa
Credit Card NO:
I I I I I I I I I I I I
_I �1_1 �II�___I ___ _ Exp. Mo
I Yr.
Print cardholder's name:
Date:
Cardholder's signature:
DOS -1246 Security Guard (Rev.5/14)
NYS DEPARTMENT OF STATE
DIVISION OF LICENSING SERVICES
PO BOX 5004, G.P.O.
NEW YORK, NY 10087-5004
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 Section 175.35 of the Penal Law. It is a class E felony to offer a
Instructions: false instrument for filing with a state or local government with the
intent to defraud.
1 Answer all application questions and sign the Affirmation.
will not be processed without all of this information.
Your renewal Training Requirements
It you are not In compliance with these training requirements, you
Check the preprinted information (top left) and enter any changes in the may not submit this renewal form.
2
space at right. It is important that you notify this Division of any
changes to your residential address so you continue to receive renewal In order to renew your registration, the required training courses must
notices and any other notifications pertinent to your registration. be completed and on file with our office. The reverse side of this
application displays your training currently on file wtth our office. The
following courses are required:
NOTE: If your name has changed (including changes due to marital 1 6-Hour On-The Job(OJT) - renewal form must display date if
status), please indicate the changes in the spaces to the right of the employed for over 90 days.
preprinted info rmation. You must provide proof of such change of 8-Hour Annual In-Service - must be completed within each
name, e.g., a copy of one of the following: year of your license term; renewal form must display two
completion dates
Court order changing your name If registered with our office to carry a firearm, you must also complete:
Marriage certificate
8-Hour Annual Firearms Course - must be completed each
Driver's license, or a non-driver's ID card
Valid passport calendar year; renewal form must display two completion dates
Immigration documents
Photo ID Card
Warning: The Department of State will not accept documents with
alterations or erasures. Presentation of fraudulent documents may also Your photo ID card will be produced by the NYS Department of Motor
result in criminal prosecution. Vehicles using the image on file in their office. If you have a valid NYS
Driver License or Non-Driver ID with photo, please read the section
3 Mail this completed, signed. original renewal notice wrth your $25
"Informed Consent" on the reverse side of this notice, sign and date tt.
nonrefundable fee. You may pay by check or money order made
payable to the NYS Department of State or charge any fee to
MasterCard or Visa. A $20 fee will be charged for any check Failure to adhere to these instructions will delay
returned by your bank. issuance of your new registration.
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Please fold here to ensure the address below appears in the window of the return envelope.
* * * DO NOT CUT - PLEASE RETURN ENTIRE FORM FOR PROCESSING * * *
Security Guard Renewal Application
Questions? Contact the Division of Licensing
Services at (518) 474-7569. Please reference
your Unique ID Number in all communications.
DO NOT DELAY: You cannot work as a security
guard if you do not renew your registration by the
expiration date of your current registration.
Additionally if you do not renew your registration
within 6 months after the expiration of your
current registration, you will have to reapply and NYS DEPARTMENT OF STATE
requalify. DIVISION OF LICENSING SERVICES
PO BOX 5004, G.P.O.
NEWYORK, NY 10087-5004