09 Page 1 of 2 New York State DEPARTMENT OF STATE Division of Licensing Services PO Box 22001 Customer Service 518 474 4429 Albany NY 12201 2001 wwwdosnygov Proprietary Security Guard Employer Please tak ID: 4778
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DOSa (Rev. Page 1 of 2 New York StateDEPARTMENT OF STATEDivision of Licensing ServicesP.O. Box 22001 Customer Service: (518) 474Albany, NY 12201 PRIVACY NOTIFICATION Do I need to provide my Social Security and Federal ID numbers on the application ��DOS a (Rev. 12/09) Page 2 of 2 A B C 1 2 3 ProprietarySecurityGuard haveattachedthecertificateinsuranceevidencingcomprehensivegeneralliabilitycoveragetheminimumamount$100,000peroccurrenceand$300,000theaggregateYECoordinatoName:LASNAMEFIRSNAMEMIDDLNAMENAMSUFFIX X Applicant’sSignatureDateSignedBelowPleasenteUniquIdentificatioNumber(spreviouslassignebusinesDivisioLicensinServices:Applicantpleaseinitial