OCFS-4930ASFA (Rev. 5/2013)

New York State

Office of Children & Family Services

Request for NYS Fingerprinting Services

Information Form

(To be completed by Provider or Foster Care/Adoption Agency)

Enrollment Information:

Applicant must have an appointment to be fingerprinted. At appointment, applicant will need to bring this form and acceptable ID as noted on reverse.

Appointments can be obtained by contacting vendor at one of the following:

Website: www.Identogo.com or the Call Center: 877-472-6915

Contributor Agency Section:
ORI:	NY922130Z	Contributor Agency:	NYS Office of Children & Family Services
Job or License Type:	Child Day Care ( Foster Care/Adoption Mentor

OCFS Employee (employee / peace officer – please circle one)
Facility/Agency ID Number:	Additional Agency ID Info:
(Foster Care/Adoption Only)
Facility Name/Address:

Applicant Section:	New Submission Resubmission
Name of Applicant:
Alias / Maiden Name:
Street Address:
City, State, & Zip:
Date of Birth:	Sex:	Male Female Other	Ethnicity:	Hispanic Non Hispanic
Race:	White Black American Indian/Alaskan Native Asian/Pacific Islander

Other Unknown
Skin Tone:	Eye Color:	Hair Color:
Height:	ft	in	Weight:	lbs.
State / Country of Birth:

Role of Applicant (please check one):
CHILD DAY CARE:	Director Provider Employee/Teacher/Volunteer Household Member over 18 yrs
FOSTER CARE:	Foster Parent Relative Foster Parent Household Member over 18 yrs

Foster Child
ADOPTION:	Adoptive Parent Household Member over 18 yrs

Additional Information: (Foster Care Only)
CONNECTIONS Home Resource ID#
CONNECTIONS Person ID#

OCFS-4930ASFA (Rev. 5/2013)

Accepted Forms of Identification:

NOTE: Applicant MUST present two (2) forms of ID, at least one of which must have a photo (see Column A):
Column A - Valid Photo Identification:

U.S. Passport (unexpired or expired)

Permanent Resident Card

Alien Registration Receipt Card

Unexpired Foreign Passport

Driver’s License or Photo ID Card

(issued by U.S. State or Territory)

School or College ID Card (with photo)

Unexpired Employment Authorization

with photo (Form I-766, I-688, I-688A or B)

Photo ID Card issued by federal, state, or local govt.

Column B - Valid Supplementary Identification:

Voter registration card

U.S. Military card or draft record

Military dependent’s ID card

Coast Guard Merchant Mariner Card

Native American Tribal Document

Canadian Driver’s License

U.S. Social Security Card

Original or certified copy of a Birth Certificate

issued by authorized U.S. agency with official seal

Certification of Birth Abroad (issued by U.S.

Department of State)

U.S. Citizen ID Card (Form I-7)
Identification if under 18 and nothing else available:

School record or report card

Clinic, doctor, or hospital record

Enrollment Website address: www.Identogo.com

Call Center phone number: 877-472-6915

DCJS (Rev. 8 – 8/09)

DCJS (Rev. 8 – 01/02/09)

Application Form for Livescan Fingerprinting

tempuser

2014-04-03

Santiago, Ken (OCFS)

NYS DCJS