OCFS-4930 (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: N/A (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# N/A CONNECTIONS Person ID# N/A OCFS-4930 (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)