Fillable Printable Form HAZ-600 - Request for Fingerprinting Services - New York

Form HAZ-600 - Request for Fingerprinting Services - New York

Before completing this form, please read the instructions on page 2

REQUEST FOR NYS FINGERPRINTING

SERVICES - INFORMATION FORM

ORI

NYSHAZMAT

CONTRIBUTOR AGENCY

NYS Department of Motor Vehicles

JOB OR LICENSE TYPE

HazMat Driver

Last, First, Middle, Suffix

PAGE 1 OF 2

HAZ-600 (7/15)

Section 1: Carrier Information

Section 2: Applicant Information

License ID Number: Enter the 9-digit number from the NYS commercial driver license.

Name of Applicant: Enter the name exactly as it appears on the applicant’s NYS commercial driver license

Alias/Maiden Name: (If applicable)

Billing Account Number(If applicable)

You need this information

to schedule your appointment

to be fingerprinted:

Street # and Name

Country

Home Address:

City State Zip Code

Daytime Phone Number:

Area Code

( )

Date of Birth:

Daytime Phone Type

o Cell o Home o Work o Pager o Other

Gender:

o Male o Female

Height:

__________ Feet __________ Inches

Month Day Year

Race:

Skin Tone:

Place of Birth:

State

Country of Citizenship:

Alien Registration Number (If applicable)

Ethnicity:

Hair Color: Eye Color

o Hispanic o Non Hispanic o Unknown

Age

Weight:

_____________ lbs.

Important Information About FBI Record Checks: Your fingerprints will be used to check the criminal history records of the

FBI. You have the right to review the information on your FBI record. If you believe your record is incorrect or incomplete, you

can request that it be changed, corrected, or updated. For more information and instructions, visit the FBI web site at:

http://www.fbi.gov/about-us/cjis/criminal-history-summary-check

reset/clear

PAGE 2 OF 2

HAZ-600 (7/15)

INSTRUCTIONS

1. The first proof must be a valid NYS photo commercial driver license or an interim NYS commercial driver license accompanied

by a NYS non-commercial photo driver license.

2. The second proof of identification can be any of the documents listed below; the document must be valid, not expired. The first and

last names on the second proof of identification must exactly match the first and last names as they appear on the driver license

If they do not match, an official document must be submitted to explain the discrepancy (for example, a marriage certificate,

divorce papers, an adoption certificate, etc.). If information on the second proof does not match the corresponding information on the

driver license, and you cannot provide a document to explain the discrepancy, you will not be fingerprinted; you must take appropriate

action to correct the discrepancy, then reschedule your fingerprinting appointment.

w U.S. Passport (not expired)

w Certified copy of a birth certificate filed with a State Office of Vital Statistics or equivalent agency in the applicant’s state of birth,

Puerto Rico, Virgin Islands, Guam, American Samoa, or the Commonwealth of the Northern Mariana Islands

w Consular Report of Birth Abroad issued by the U.S. Department of State (Form FS-545 or DS-1350)

w Certificate of Naturalization issued by the U.S. Department of Homeland Security (Form N-550 or N-570)

w Certificate of Citizenship issued by the U.S. Department of Homeland Security (Form N-560 or N-561)

w Permanent Resident Card (not expired) issued by USCIS or INS (Form I-551)

ACCEPTABLE DOCUMENTS FOR PROOF OF IDENTITY

Applicants MUST bring two (2) proofs of identification to the fingerprinting site:

Please direct any questions to the New York State Department of Motor Vehicles HazMat Unit at (518) 408-2997.

IMPORTANT!

This form, when completed, provides personal information which is confidential. The completed form should not be left at the

fingerprinting site - the applicant should either retain it for his/her records or dispose of it properly (shredding it is recommended).

Ø When completed, this form must not be retained, photocopied, or otherwise reproduced by the MorphoTrust staff.

Ø The information provided on this form must not be retained by the MorphoTrust staff.

Federal and state laws require that commercial drivers who apply for a hazardous materials (hazmat) endorsement be fingerprinted as part of

the qualification procedure. The required fingerprinting service is being provided by MorphoTrust Enrollment Solutions (MorphoTrust). All

hazmat endorsement applicants must be fingerprinted at one of the MorphoTrust ID centers located throughout New York State.

Fingerprinting is done by appointment. Selecting a fingerprinting location, scheduling an appointment, and getting information about the

required fee can be done online at www.identogo.com or by calling 1-877-472-6915.

This form must be completed as described below and taken to the fingerprinting site at the time of the appointment. In addition to this form,

the applicant must bring two acceptable proofs of identification (acceptable proofs are listed below under Acceptable Documents for

Proof of Identity).

Section 1 - Carrier Information: If the carrier is going to pay the required fee on behalf of the applicant and the carrier has established

an escrow account with MorphoTrust, the carrier must provide the escrow account number in the Billing Account Number field.

Section 2 - Applicant Information: Provide all of the information that is requested. The applicant must possess a valid NYS photo

commercial driver license or an Interim NYS commercial driver license accompanied by a NYS non-commercial photo license in order to

apply for the hazmat endorsement.

NOTE: The applicant’s name and date of birth written on this form must exactly match the name and date of birth as it appears

on the NYS commercial driver license.

The Privacy Act of 1974 5 U.S.C. 552a(e)(3)

Privacy Act Statement Authority: 6 U.S.C. § 1140, 46 U.S.C. § 70105; 49 U.S.C. §§ 106, 114, 5103a, 40103(b)(3), 40113, 44903, 44935-

44936, 44939, and 46105; the Implementing Recommendations of the 9/11 Commission Act of 2007, § 1520 (121 Stat. 444, Public Law

110-52, August 3, 2007); and Executive Order 9397, as amended.

Purpose: The Department of Homeland Security (DHS) will use the biographic information to conduct a security threat assessment. Your

fingerprints and associated information will be provided to the Federal Bureau of Investigation (FBI) for the purpose of comparing your

fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems including civil, criminal,

and latent fingerprint repositories. The FBI may retain your fingerprints and associated information in NGI after the completion of this

application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

DHS will also transmit your fingerprints for enrollment into US-VISIT Automated Biometrics Identification System (IDENT). If you provide

your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security Administration (SSA) to compare that

information against SSA records to ensure the validity of the information.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act, all or a portion of the records

or information contained in this system may be disclosed outside DHS as a routine use pursuant to 5 U.S.C. 522a(b)(3) including with third

parties during the course of a security threat assessment, employment investigation, or adjudication of a waiver or appeal request to the

extent necessary to obtain information pertinent to the assessment, investigation, or adjudication of your application or in accordance with

the routine uses identified in the TSA system of records notice (SORN) DHS/TSA 002, Transportation Security Threat Assessment System.

For as long as your fingerprints and associated information are retained in NGI, your information may be disclosed pursuant to your consent

or without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the

Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses.

Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide your SSN or any other information

requested, DHS may be unable to complete your application for a security threat assessment.