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Richard Archer

Richard Archer

Stormville,NY

Work History

Customer Service

SOCIAL SECURITY NUMBERS
  • (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), Section34
  • 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
  • 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

One Commerce Plaza
  • 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 register online, please visit www.ny.gov/services/register-vote.

GUARD

APPLICANT AFFIRMATION
  • 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
  • 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
  • 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
  • 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

Sections

  • 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.
  • 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.
  • 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/aboutus/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.
  • 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. 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.
  • Security Guard Training Advisory, Waivers/Exemptions from Mandated TrainingSecurity 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 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.
  • 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:
  • 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.
  • 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, 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.
  • 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.
  • 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 signing below, you certify that you are:
  • 16 years of age or older;
  • Consenting to donate your organs and tissues for transplantation and/or research in the event of your death;
  • Authorizing the New York Department of State, Division of Licensing Services to transfer your name and identifying information to the NYS Donate Life Registry for enrollment; and
  • Authorizing the Registry to give access to this information to federally regulated organ procurement organizations and NYS-licensed tissue and eye banks and others approved by the NYS Commissioner of Health in the event of your death.
  • Sign
  • Date

Locations

P.O. Box 22052, Albany, NY, 12201-2052

Timeline

Customer Service

SOCIAL SECURITY NUMBERS

One Commerce Plaza

GUARD

APPLICANT AFFIRMATION

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Richard Archer