Request for Criminal History Record Check - New York 2026

1. Click ‘Get Form’ to open the Request for Criminal History Record Check in the editor.
2. Begin by filling in your Agency/DDSO/Registered Provider Name and Five Digit ID Number. Ensure that all entries are clear and legible.
3. Complete the applicant's personal information, including Last Name, First Name, Middle Initial, Date of Birth, and Social Security Number.
4. Provide the applicant's address details: Street Address or PO Box, City, State, and Zip Code.
5. Select the appropriate Status by checking one of the options: Employee (non-state), Volunteer, Family Care Provider, or Employees of vendors and contractors.
6. Indicate the Program Type by entering a four-digit code from page 2 or selecting from the provided options.
7. Ensure that an Authorized Person signs and dates the form at the bottom. If Livescan prints are required, hand over the completed form to the applicant for submission.

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