OCFS-4930 (8/2009) 

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.L1Enrollment.com or the Call Center: 877-472-6915 

Contributor Agency Section:
ORI: NY922130Z Contributor NYS Office of Children & Family Services 


 
Foster Care/Adoption 
Mentor
Job or License Type: . Child Day Care

 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: 

 
New Submission 
Resubmission 
Applicant Section:

Name of Applicant: 

Alias / Maiden Name: 

Street Address: 

City, State, & Zip: 

Date of Birth: 
Race: White 
Other 
Sex: 
Black 
Unknown 
Male Female Other Ethnicity: Hispanic Non Hispanic 
American Indian/Alaskan Native Asian/Pacific Islander 
Skin Tone: 
Height: 
State / Country of Birth: 
ft 
Eye Color: 
in Weight: 
Hair Color: 
lbs. 

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 

DCJS (Rev. 8 � 8/09) 


OCFS-4930 (8/2009) 

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: 

Column B - Valid Supplementary Identification: 

U.S. Passport (unexpired or expired) 
Voter registration card 
Permanent Resident Card 

U.S. Military card or draft record 
Alien Registration Receipt Card 
Military dependent�s ID card 
Unexpired Foreign Passport 

Coast Guard Merchant Mariner Card 
Driver�s License or Photo ID Card

Native American Tribal Document 
(issued by U.S. State or Territory) 


Canadian Driver�s License 
School or College ID Card (with photo) 

U.S. Social Security Card 
Unexpired Employment Authorization
Original or certified copy of a Birth Certificate 
with photo (Form I-766, I-688, I-688A or B) 


 issued by authorized U.S. agency with official seal 
Photo ID Card issued by federal, state, or local govt. 

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.L1Enrollment.com 
Call Center phone number: 877-472-6915 

DCJS (Rev. 8 � 8/09)