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									                       INSTRUCTIONS FOR COMPLETING
 ELECTRICAL CONTRACTORS’ LICENSING BOARD INITIAL CERTIFIED LICENSE APPLICATION
                               DBPR ECLB 4459

                                      Application begins on page 7

If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

Applicants are cautioned to read questions thoroughly. Be certain that all questions are answered
truthfully and that all requested information is furnished. Please type or print in ink.

REFUND POLICY
Please be advised, per Section 489.509(1), Florida Statutes, application fees are not refundable.

QUALIFICATIONS
Applicants must be at least 18 years of age, be of good moral character, meet the education/experience
requirements, and pay all applicable fees.

Certification by Examination
In order to become a licensed certified contractor in the State of Florida by examination, an applicant
must meet educational and/or experience requirements, pass the state certification examination, show
evidence of workers’ compensation coverage, and demonstrate financial responsibility. A “certified
contractor” means any contractor who possesses a license issued by the department and who shall be
allowed to contract in any jurisdiction in the state without being required to fulfill the local competency
requirements of that jurisdiction.

Certification by Endorsement
In order to become a licensed certified contractor in the State of Florida by endorsement, an applicant
must meet educational and/or experience requirements, show evidence of having passed an exam
substantially similar* to the State of Florida certification examination, show evidence of workers’
compensation coverage, and demonstrate financial responsibility.

* Prior to Certification by Endorsement from any state or category not listed below, the Department’s Bureau
of Education and Testing must review and approve an Examination Evaluation Questionnaire completed by
the testing authority for that home state. The Department will send the Examination Evaluation Questionnaire
to the state where you took your examination after receipt of a completed application. This questionnaire will
be used to establish endorsements between Florida and other states on as state-by-state and exam-by-exam
basis. An applicant must have obtained his or her license through examination from the state of
endorsement. It is the responsibility of the applicant to provide this home state’s contact information and
other documentation (including examination vendor information) so that the board can determine whether the
examination taken is substantially equivalent to the examination required by section 489.511(1), Florida
Statutes. Please note - if your exam was given by Experior/Thompson Prometric we will not be able to make
a comparison due to their confidentiality policies.

Individuals who hold one of the licenses below and having taken and passed that states examination may
be eligible for endorsement. For information on states or examinations other than those listed, contact
the Department of Business and Professional Regulation at 850-487-1395.

THE FOLLOWING EXAMS MAY BE SUBSTANTIALLY SIMILAR FOR THE PURPOSES OF
ENDORSEMENT:
   • Florida Unlimited Electrical (EC) = North Carolina Unlimited, California Electrical C-10 License,
      Georgia Class II Unrestricted and Low Voltage Unlimited (Must Hold Both Georgia Licenses To
      Be Eligible)
   • Florida Residential Specialty (ES) = Georgia Class I, North Carolina Limited License (L)
   • Florida (Low Voltage) Limited Energy (ES) = California Electrical C-7 License Exam, North
      Carolina Low Voltage (SP-L/V)




2010 August                                      Page 1 of 24               ECLB Initial Certified License Application
APPLICATION REQUIREMENTS AND SUPPORTING DOCUMENT FOR INITIAL CERTIFICATION BY
                       EXAMINATION OR ENDORSEMENT

The following documents are required in order to process your application. These documents are Board
approved and cannot be substituted.

1. W-2 FORMS: Copies of W-2 forms must be provided for each year of experience as listed on the
   applicant job list. If you are self employed you can provide Schedule C or K-1 forms from your tax
   returns in lieu of W-2 forms.

2. WORK EXPERIENCE FORM: List employment in chronological order, starting with most current
   employment, and include a detailed job description. Complete one form for each employer named on
   the job list on page 10 of the application. Please reproduce this form as needed.

3. EMPLOYMENT VERIFICATION FORMS: Employment verification forms confirming employment. If
   you are self-employed, you must submit three (3) original notarized letters from contractors, building
   officials, or local licensing/inspection authorities.

4. JOB LIST: A representative list of jobs performed during the time frames is required to determine
   eligibility. You must list at least five (5) jobs for each year of experience claimed on page 8 as
   qualification for licensure. This list should be in chronological order starting with the most recent job
   and must include starting and ending dates, locations, and a detailed description of work performed.

5. APPLICANT CREDIT REPORT: A credit report on the qualifying agent from any recognized credit
   bureau that includes, but is not limited to, liens, judgments, suits, and bankruptcy obtained from
   county, state and federal records. The credit report must be dated within twelve (12) months of filing
   this application and must include the following statement: “PUBLIC RECORDS HAVE BEEN
   SEARCHED AT THE COUNTY, STATE AND FEDERAL LEVELS.” Go to
   http://www.myfloridalicense.com/dbpr/pro/elboard/index.html for a list of acceptable agencies.

6. BUSINESS CREDIT REPORT: A credit report on the business to be qualified from any recognized
   credit bureau that includes, but is not limited to, liens, judgments, suits, and bankruptcy obtained from
   county, state and federal records. The credit report must be dated within twelve (12) months of filing
   this application and must include the following statement: “PUBLIC RECORDS HAVE BEEN
   SEARCHED AT THE COUNTY, STATE AND FEDERAL LEVELS”. Go to
   http://www.myfloridalicense.com/dbpr/pro/elboard/index.html for a list of acceptable agencies.

7. PERSONAL FINANCIAL STATEMENT: Personal financial statement of the applicant must be
   prepared within twelve (12) months of filing this application and must show a positive net worth. Your
   personal financial statement must be signed in the presence of a notary, unless prepared by a
   Certified Public Accountant. See Rule 61G6-5.003, F.A.C. for a more detailed explanation of this
   requirement.

8. BUSINESS FINANCIAL STATEMENT: Business financial statement must be prepared within twelve
   (12) months of filing this application and must show a total net worth of:

        $10,000 for Certified Electrical, Certified Alarm I and Certified Alarm II Contractors
        $5,000 for Certified Specialty Contractors

9. LETTER OF FINANCIAL RESPONSIBILITY: Applicant must submit 1 of the following:
        •     An original notarized letter from your bank, on bank letterhead, verifying the applicant’s
              authority to sign checks on the business account (see Rule 61G6-5.004(5), F.A.C. for
              explanation) or
        •     An original notarized letter from the C.F.O. of the business stating the applicant has the
              authority to sign checks payments, drafts and contracts on behalf of the business. Note: The
              letter can not be written by the applicant.




2010 August                                       Page 2 of 24              ECLB Initial Certified License Application
10. LETTER OF SUPERVISORY RESPONSIBILITY - If the licensee is not an officer of the company, you
    must submit an original letter of supervisory status from the President of the company stating the
    licensee has the authority to approve all electrical work performed by the business.

11. FINANCIAL RESPONSIBILITY QUESTIONNAIRE: Provide explanation and documentation for any
    YES answers. Documentation for liens, judgment or suits must include legal release, settlement or
    adjudication.
       Liens
           Form 668 Certificate of Release of Federal Tax Lien
           Form UCC#3 Certificate of Release of State Tax Lien
       Judgments
           Form B27 United States Bankruptcy Court of Discharge of Debtor
       Suits
           Settlement document from the court in which the suit was filed

 LICENSURE CATEGORIES


 EC – Certified Electrical Contractor (Unlimited)           ES – Certified Specialty Contractor:
 EF – Certified Alarm System                                       • Residential Electrical Specialty
          Contractor I (All Alarm Systems)                         • Lighting Maintenance Specialty
 EG – Certified Alarm System                                       • Sign Specialty
          Contractor II (Excluding Fire)                           • Limited Energy System Specialty
                                                                   • Utility Line Electrical Specialty


 EDUCATION/EXPERIENCE REQUIREMENTS
 Below is a listing of each license category and the corresponding education/experience requirements.
 Locate the license category for which you are applying to determine whether you meet the requirements
 for examination.
                                 Education/Experience Requirement – (References: Section 489.511,
    License Category
                                                     F.S., Rule 61G6-6-5.003, F.A.C)
                                  Must be licensed as an electrical professional engineer for three (3)
                                  years within the last 12 years; or
                                  Must have three (3) years of management experience in the trade within
                                  the last six (6) years immediately preceding the filing of the application;
                                  or
                                  Must have four (4) years of experience as a foreman, supervisor or
                                  contractor in the trade within the last eight (8) years immediately
                                  preceding the filing of the application; or
ALL CATEGORIES                    Must have six (6) years of comprehensive training, technical education or
                                  broad experience associated with an electrical contracting business
                                  within the last 12 years immediately preceding the filing of the
                                  application; or
                                  Must have at least six (6) years of technical experience in electrical work
                                  with the Armed Forces or a governmental entity within the last 12 years
                                  immediately preceding the filing of the application; or
                                  Must have a combination of these qualifications totaling six (6) years of
                                  experience.
EC – Certified Electrical         The required experience must include at least 40% of work that is in 3-
Contractor                        phase services.
EF – Certified Alarm
                                   The required experience must include at least 40% of work that is in fire
System Contractor I (All
                                   alarm systems.
Alarm Systems)
EG – Certified Alarm
                                   The required experience must include at least 40% of work that is in
System Contractor II
                                   alarm systems other than fire alarm systems.
(Excluding Fire)



 2010 August                                        Page 3 of 24            ECLB Initial Certified License Application
 REQUIREMENTS FOR PROFESSIONAL ENGINEERS & APPLICANTS WITH DEGREES

 If you are a licensed professional engineer or hold a degree in an engineering or related field, you must
 comply with the corresponding requirements as listed below:

                               Must be licensed as an electrical professional engineer for three (3) years
                               within the last 12 years.
Licensed
                               Applicant is required to submit a copy of professional engineer license,
Professional
                               copies of college or university transcripts verifying degree was in electrical
Engineer
                               engineering and all parts of the application excluding the W2 forms, job list,
                               and employment history and verification form.
                               An applicant for examination who is a recipient of a degree in engineering or
Applicant with
                               related field from an accredited four-year college or university may substitute
Degree in
                               his or her educational background for 1 ½ years of experience in the trade as
Engineering or
                               an electrical or alarm contractor, provided that the college or university he or
Related Field
                               she attended forwards a copy of his or her transcripts to the Department.

                                     APPLICATION CHECKLISTS


TRANSACTION                                       APPLICATION REQUIREMENTS

Initial Application for Certification by            FEES:
Examination – Inactive                                  Pay $55.00 fee (make check payable to the
                                                        Department of Business and Professional
(You must have already passed the State of              Regulation).
Florida Electrical Contractors                      FORMS:
Technical/Safety and Business                           Complete DBPR ECLB 4459 – Initial Certified
examinations – passing test scores must be              License Application
less than 2 years old to be valid)                      Complete DBPR 0010 – Master Individual
                                                        Application
                                                        Complete DBPR 0050 – Explanatory Information
                                                        for Background Questions (if applicable)
                                                        Complete DBPR 0060 – General Explanatory
                                                        Description (if applicable)

* If you submitted documentation of               SUPPORTING DOCUMENTS:
experience as part of you examination                              Applicant Information *
application – you do not need to resubmit            W-2 Forms
those items. Please indicate on page 7 that          IF SELF EMPLOYED – Submit three original
you wish to have those items reviewed as             notarized letters from contractors, building officials, or
part of your licensure application.                  local licensing/inspection authorities, verifying
                                                     experience in lieu of Employment Verification Form
                                                     (Page 12).
                                                     Personal credit report ** not older than twelve months,
                                                     from recognized credit bureau.
** Credit Reports must include statement that        Documents providing proof of satisfaction for liens,
public records have been searched at county,         judgments, or explaining pending lawsuits.
state, and federal levels. Go to                     Criminal History: If you respond yes to question #1 on
http://www.state.fl.us/dbpr/pro/elboard/elec_in      the background questionnaire you must provide
dex.shtml for a list of acceptable agencies          certified copies of the charging document and
                                                     judgment/sentence, as well as copies of any orders
                                                     terminating probation.
                                                     If using education as part of experience requirement
                                                     you must submit transcripts.




 2010 August                                      Page 4 of 24             ECLB Initial Certified License Application
TRANSACTION                                           APPLICATION REQUIREMENTS
Initial Application for Certification
by Examination – Active                                 FEES:
                                                            Pay $300.00 fee (make check payable to the
(You must have already passed the State of                  Department of Business and Professional
Florida Electrical Contractors                              Regulation).
Technical/Safety and Business                           FORMS:
examinations – passing test scores must be                  Complete DBPR ECLB 4459 – Initial Certified
less than 2 years old to be valid)                          License Application
                                                            Complete DBPR 0010 – Master Individual
                                                            Application
                                                            Complete DBPR 0020 – Master Organization
* If you submitted documentation of                         Application
experience as part of you Examination                       Complete DBPR 0050 – Explanatory Information
application – you do not need to resubmit                   for Background Questions (if applicable)
those items. Please indicate on page 7 that                 Complete DBPR 0060 – General Explanatory
you wish to have those items reviewed as                    Description (if applicable)
part of your licensure application.
                                                      SUPPORTING DOCUMENTS:
                                                                       Applicant Information *
**Credit Reports must include statement that             W-2 Forms*
public records have been searched at county,             IF SELF EMPLOYED – Submit three original
state, and federal levels. Go to                         notarized letters from contractors, building officials,
http://www.state.fl.us/dbpr/pro/elboard/elec_in          or local licensing/inspection authorities, verifying
dex.shtml for a list of acceptable agencies              experience in lieu of Employment Verification Form
                                                         (Page 12).
                                                         Personal credit report**, not older than twelve
*** Verification of supervising employee                 months, from recognized credit bureau.
status – This is a letter signed by the                  Documents providing proof of satisfaction for liens,
President of the company stating the Qualifying          judgments, or explaining pending lawsuits.
Agent is legally qualified to act for the business       Criminal History: If you respond yes to question #1
organization in all matters connected with its           on the background questionnaire you must provide
contracting business and has the authority to            certified copies of the charging document and
supervise all electrical work undertaken by the          judgment/sentence, as well as copies of any orders
business organization.                                   terminating probation.
                                                         If using education as part of experience requirement
****Letter of Financial Responsibility - An              you must submit transcripts.
original notarized letter from your bank, on             If using your Professional Engineer’s License as a
bank letterhead, verifying the applicant’s               qualification you must submit a copy of the license
authority to sign checks on the business                 and a transcript of your education.
account or an original notarized letter from the
C.F.O. of the business stating the applicant                    Business to be Qualified Information
has the authority to sign checks payments,                     (Secondary Qualifiers see note on left)
drafts and contracts on behalf of the business.
Note: The letter can not be written by the                Original notarized letter of financial responsibility****
applicant.                                                see Rule 61G6-5.004(5), F.A.C. for explanation.
                                                          Verification of supervising employee status*** if not
Note: if you are applying as secondary                    an officer.
qualifier or an additional primary - you are              Business credit report** not older than twelve months,
not required to submit the following items:               from recognized credit bureau.
• Business financial statement (page 16)
• Statement of bonding or the irrevocable
    letter of credit (pages 17 & 18)
• Business credit report




 2010 August                                         Page 5 of 24              ECLB Initial Certified License Application
                TRANSACTION                                        APPLICATION REQUIREMENTS
Initial Application for Certification                    IF YOUR LICENSE IS NOT LISTED ON THE LEFT
by Endorsement – Active                                    YOU MUST SUBMIT THE FOLLOWING ITEMS:
                                                           The examination blueprint/outline for the examination
THE FOLLOWING EXAMS MAY BE                                 you took to become licensed for the year you passed
SUBSTANTIALLY SIMILAR FOR THE                              the examination in that state.
PURPOSES OF ENDORSEMENT:                                   Provide contact information for the licensing board
                                                           and examination administrator/vendor (Page 8).
Florida Unlimited Electrical (EC) = North                  The Statutes and Rules governing your license from
Carolina Unlimited, California Electrical C-10             the state where you received your license for the
License, Georgia Class II Unrestricted and Low             year you became licensed in that state.
Voltage Unlimited (Must Hold Both Georgia             FEES:
Licenses To Be Eligible)                                 Pay $500 fee (make check payable to the
                                                         Department of Business and Professional
Florida Residential Specialty (ES) =                     Regulation).
Georgia Class I, North Carolina Limited
License (L)                                           FORMS:
                                                         Complete DBPR ECLB 4459 – Initial Certified
Florida (Low Voltage) Limited Energy (ES) =              License Application
California Electrical C-7 License Exam, North            Complete DBPR 0010 – Master Individual
Carolina Low Voltage (SP-L/V)                            Complete DBPR 0020 – Master Organization
                                                         Complete DBPR 0050 – Explanatory Information for
* Credit Reports must include statement that             Background Questions (if applicable)
public records have been searched at county,             Complete DBPR 0060 – General Explanatory
state, and federal levels. Go to                         Description (if applicable)
http://www.state.fl.us/dbpr/pro/elboard/elec_in
dex.shtml for a list of acceptable agencies           SUPPORTING DOCUMENTS:
                                                                       Applicant Information
** Verification of supervising employee                  W-2 Forms
                                                         IF SELF EMPLOYED – Submit three original
status – This is a letter signed by the
President of the company stating the Qualifying          notarized letters from contractors, building officials,
Agent is legally qualified to act for the business       or local licensing/inspection authorities, verifying
                                                         experience in lieu of Employment Verification Form
organization in all matters connected with its
contracting business and has the authority to            (Page 12).
supervise all electrical work undertaken by the          Official Letter of License Verification and Good
                                                         Standing from Endorsing State (Page 9).
business organization.
                                                         Personal credit report* not older than twelve months,
****Letter of Financial Responsibility - An              from recognized credit bureau.
                                                         Documents providing proof of satisfaction for liens,
original notarized letter from your bank, on
bank letterhead, verifying the applicant’s               judgments, or explaining pending lawsuits.
authority to sign checks on the business                 Criminal History: If you respond yes to question #1
account or an original notarized letter from the         on the background questionnaire you must provide
C.F.O. of the business stating the applicant             certified copies of the charging document and
                                                         judgment/sentence, as well as copies of any orders
has the authority to sign checks payments,
drafts and contracts on behalf of the business.          terminating probation.
                                                         If using education as part of experience requirement
Note: The letter can not be written by the
                                                         you must submit transcripts.
applicant.

Note: if you are applying as secondary                          Business to be Qualified Information
                                                               (Secondary Qualifiers see note on left)
qualifier or an additional primary - you are
                                                          Original notarized letter of financial responsibility**** –
not required to submit the following items:
                                                          see Rule 61G6-5.004(5), F.A.C. for explanation.
• Business financial statement (page 16)
                                                          Verification of supervising employee status** if not an
• Statement of bonding or the irrevocable
                                                          officer.
    letter of credit (pages 17 & 18)
                                                          Business credit report* not older than twelve months,
• Business credit report                                  from recognized credit bureau.




 2010 August                                         Page 6 of 24               ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application

                                      STATE OF FLORIDA
                              DEPARTMENT OF BUSINESS AND
                                PROFESSIONAL REGULATION
                                   1940 North Monroe Street
                                 Tallahassee, FL 32399-0783
                        NOTE – This form must be submitted as part of an
                                   entire application packet

If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

                                      APPLICANT INFORMATION
Last Name                               First            Middle                     Title                Suffix




                                  CHECK TRANSACTION REQUESTED
Transaction Type:
   Initial Certification by Examination (Active) – $300.00 fee required [1030]
   Initial Certification by Examination (Inactive) – $55.00 fee required [1031]
   Initial Certification by Endorsement (Active) – $500.00 fee required [1023]
                                   CHECK EXAMINATION CATEGORY
   Unlimited Electrical Contractor [0801]
   Alarm System Contractor I [0802]
   Alarm System Contractor II [0803]
   Residential Electrical Contractor [0804]
   Utility Line Contractor [0804]
   Limited Energy Contractor [0804]
   Sign Specialty Contractor [0804]
   Lighting Maintenance Contractor [0804]


  Florida Registered       Please list your current License number and date of licensure:
     Contractors           Registered License Number: ____________________________________
                           Date of Licensure: _____________________________________________
                           Note: Before Issuance of a certified license in the same category as your
                           registered license you will be required to surrender your registered
                           license and it will be cancelled.
     Experience            Indicate if this applies to you:
documentation on file         I submitted documentation of my experience (W2’s, Employment
    with D.B.P.R.          Verification forms, etc…) as part of my examination application – please
                           review those documents with this application.


ALL INITIAL CERTIFIED LICENSE APPLICATIONS REQUIRE BOARD REVIEW. After the application
is reviewed and found to be complete, it will be scheduled for an upcoming Board meeting. Applicants
are not required to attend the meeting.

Please send your completed application, documentation and required fee(s) to:

                          Department of Business and Professional Regulation
                                      1940 North Monroe Street
                                    Tallahassee, FL 32399-0783

                                        www.MyFlorida.com/dbpr


2010 August                                     Page 7 of 24              ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application
                                     QUALIFICATION FOR LICENSURE
 A person shall be eligible for licensure by meeting one of the following requirements. (Check One)

                          489.511(2)(a)(3)(a), F.S.
                             Has, within the six (6) years immediately preceding the filing of the
                             application, at least three (3) years proven “management experience” in
                             the trade or education equivalent thereto, or a combination thereof, but
                             not more than one-half of such experience may be educational
                             equivalent.
                          489.511(2)(a)(3)(b), F.S.
                             Has, within the eight (8) years immediately preceding the filing of the
                             application, at least four (4) years experience as a supervisor, foreman, or
                             contractor in the trade for which he or she is making application.
                          489.511(2)(a)(3)(c), F.S.
                             Has, within the twelve (12) years immediately preceding the filing of the
                             application, at least six (6) years of comprehensive training, technical
                             education, or supervisory experience associated with an electrical or
                             alarm system contracting business, or at least six (6) years of technical
                             experience in electrical or alarm system work with the Armed Forces or a
                             governmental entity.
                          489.511(2)(a)(3)(d), F.S.
                             Has, within the twelve (12) years immediately preceding the filing of the
                             application, been licensed for three (3) years as a professional engineer
                             who is qualified by education, training, or experience to practice electrical
                             engineering.
                          489.511(2)(a)(3)(e), F.S.
                             Has any combination of qualifications under sub-subparagraphs 1-3
                             totaling six (6) years of experience.



                                 ENDORSEMENT APPLICANTS ONLY

 State of Licensure and Examination: _______________________________________________

 License Number: ________________________ License Category: __________________________

 Below please provide contact Information for above State’s Examination Office (This is required if your
 State and License are not listed on page 1 of this package).

 Name (Individual Contact and Agency):
 ____________________________________________________
 Address:
 ____________________________________________________________________________
 City, State, Zip:
 _______________________________________________________________________
 Phone: ____________________________ Email (If Available):
 _________________________________
 Examination Vendor (if applicable):
 _______________________________________________________
 Note: Licensure by endorsement for states and licenses that are not listed on page 1 requires
 extensive review and may take several months. The requirement for the examination taken to be
 substantially similar to the Florida examination is a very high threshold and many exams are not
 accepted. Please consider applying for licensure by examination.


2010 August                                     Page 8 of 24             ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application

                              ENDORSEMENT APPLICANTS ONLY
                            Verification of Licensure in Good Standing

                                         STATE OF FLORIDA
                                   DEPARTMENT OF BUSINESS AND
                                    PROFESSIONAL REGULATION
                                      1940 North Monroe Street
                                     Tallahassee, FL 32399-0783
                                         APPLICANT INFORMATION
                                       (To Be completed by Applicant)
Name of Applicant                                          Social Security Number*

Street Address

City                                   State                                  Zip

Date of Birth                          License Number                         Telephone #

                            Verification of Licensure in Good Standing
                             (To Be Completed By State Licensing Agency)
Name of License Holder as it appears on License

Business Name as it appears on License

Date License Issued                                                 License Number

Current Status of License                                  Expiration Date of License

Classification of License Held

                                               Method of Licensure

Licensed by Examination:         Yes      No               Examination Category:

Type of Exam Taken (E.g. In House, NAI, Block):            Examination Date and Score:

Reciprocity/Endorsement from What State :                  Other Method (Please Explain):

Has the License Holder Ever Had Any Disciplinary Action Taken Against His/Her License?                   Yes        No
If Yes - Please Provide the following Information:
Date of Discipline_________________ Sanctions Imposed: ___________________________________
 Has Licensee Complied with Sanctions?            Yes        No (Please Explain)


Name of Verifying Individual                                        Title

Signature                                                  Agency

                                                           Address:

                                                           City, State, Zip
                       Seal
                                                           Telephone #:




Instructions to verifying state: Please return the original document to the licensee for
inclusion in their application package.
2010 August                                         Page 9 of 24              ECLB Initial Certified License Application
  DBPR ECLB 4459 – Initial Certified License Application

                                APPLICANT JOB LIST (DUPLICATE AS NECESSARY)
 List five jobs for each of the years you are qualifying (e.g., 3 yrs. management, 4 yrs. supervisory, or 6 yrs.
 trade) with dates that concur with documented employment. A total of 15, 20, or 30 jobs should be listed.
 Month        If you are applying for Electrical Contractor – your total years experience must include
 & Year       40% 3-phase experience. If you are applying for Alarm System Contractor I – your total
              years experience must include 40% fire alarm experience. If you are applying for Alarm
              System Contractor II – your total years experience must include 40% work in alarm
              systems other than fire.
           Electrical/Alarm Contractor’s Name________________________ License# ________________
FROM:
           Job Location Address ___________________________________________________________
TO:        Was this job Residential or Commercial _____________________________________________
Detailed description of work performed at job site:



           Electrical/Alarm Contractor’s Name________________________ License# ________________
FROM:
           Job Location Address ___________________________________________________________
TO:
           Was this job Residential or Commercial _____________________________________________
Detailed description of work performed at job site:



           Electrical/Alarm Contractor’s Name________________________ License# ________________
FROM:
           Job Location Address ___________________________________________________________

TO:         Was this job Residential or Commercial
Detailed description of work performed at job site:




           Electrical/Alarm Contractor’s Name________________________ License# ________________
FROM:
           Job Location Address ___________________________________________________________
TO:
           Was this job Residential or Commercial
Detailed description of work performed at job site:




           Electrical/Alarm Contractor’s Name________________________ License# ________________
FROM:
           Job Location Address ___________________________________________________________
TO:         Was this job Residential or Commercial
Detailed description of work performed at job site:




  2010 August                                      Page 10 of 24             ECLB Initial Certified License Application
   DBPR ECLB 4459 – Initial Certified License Application

                                                  STATE OF FLORIDA
                                           DEPARTMENT OF BUSINESS AND
                                            PROFESSIONAL REGULATION
                                               1940 North Monroe Street
                                             Tallahassee, FL 32399 – 0783

                                        NOTE – This form must be submitted as
                                         part of an entire application packet.

If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

                                         APPLICANT INFORMATION
 Last Name                                First           Middle                    Title                Suffix


                                     APPLICANT EMPLOYMENT HISTORY
                                     (DUPLICATE FORM AS NECESSARY)

 APPLICANT EMPLOYMENT HISTORY: (If you are currently a registered contractor, this information must be
 completed.) Include copies of W-2 or 1099 form(s) for employment verification. These documents must be
 attached to this form to verify time(s) of employment.

 Employer Name: ___________________________________________________________

 Telephone #: (    _)___________________

 Address: __________________________________________________________________
               (Street)

 __________________________________________________________________________
 (City)                          (State)                        (Zip)

 Date Employed:                    To _________________

 Your Supervisor: ________________________________________________________

 YOUR POSITION:                                                                Give a detailed description of your
 duties. If your position changed during this employment, list dates for each position:




   2010 August                                     Page 11 of 24             ECLB Initial Certified License Application
    DBPR ECLB 4459 – Initial Certified License Application

                          EMPLOYMENT VERIFICATION
                       MUST BE COMPLETED BY EMPLOYER
 (DUPLICATE FORM AS NECESSARY FOR EACH EMPLOYER LISTED ON APPLICANT JOB LIST)
Employing Agency / Company Name: __________________________________________________________

Qualifier Name: _______________________________ Qualifier License # _____________________________

Agency / Company Address:                                  Agency / Company Phone Number:



Current position of Applicant:                             Dates of applicant’s employment by the
                                                           Agency/Company:
                                                           From:                   To:

Current Supervisor of Applicant:

Describe in detail the applicant’s duties, including any hands-on/supervisory responsibilities:




Total time employed in a supervisory position was __________ months.

Total time employed in a managerial position was __________ months.

I attest that the information provided is true and accurate.

Print Name of Owner or Supervisor Verifying Employment: __________________________________________


Signature of Owner or Supervisor Verifying Employment: __________________________________________

Date: __________________




    If you are self-employed, disregard employment verification forms. You cannot verify your own
    employment. You must obtain at least three (3) notarized letters verifying required experience from
    building officials, local licensing agencies and licensed contractors with whom you have been associated.




    2010 August                                      Page 12 of 24             ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application
                                 PERSONAL FINANCIAL STATEMENT
Statement of Financial Condition Of: _______________________________________________
                                                 (Name of Applicant)
Date of Financial Statement:                                FEID Number:
                 ASSETS (Omit Cents)                                               LIABILITIES (Omit Cents)
1. Cash in Bank                          $                        14. Accounts Payable                   $

2. Accounts and Notes                    $                        15. Notes Payable to Banks             $
Receivable                                                        and Others
                                                                  (i.e., vehicles/equipment,
                                                                  etc…)
3. Inventory, i.e., supplies             $                        16. Mortgages and Bonds                $
                                                                  Payable
4. US Government Securities              $                        17. Unpaid Taxes                       $

5. Other Current Assets, i.e.,           $                        18. Wages & Interest                   $
vehicles (itemize)
                                         $                        19. Other Liabilities                  $
                                                                  (if corporation)
                                         $

6. Real Estate                           $

7. Buildings-Net                         $
(after depreciation)
8. Machinery, Fixtures &                 $
Equipment
(after depreciation)
9. Leasehold Improvements-               $
Net (after amortization)
10. Cash Surrender Value of              $
Life Insurance
11. Stock & Bonds                        $

12. Other Assets                         $
(itemize)
                                         $

13. Total Assets (add items 1            $                        20. Total Liabilities                  $
thru 12 above)                                                    (add items 14 thru 19
                                                                  above)
                                                                  21. Net Worth (Subtract                $
                                                                  Item 20 from Item 13.)
                                                                  TOTAL LIABILITIES/ NET
TOTAL from Line 13                       $                        WORTH – Add lines 20 and               $
                                                                  21
     PLEASE NOTE THAT THE TOTAL ASSETS COLUMN AND TOTAL LIABILITIES/NET WORTH
                       COLUMN MUST EQUAL THE SAME AMOUNT.

+*Per Rule 61G6-5.003(2)(a), F.A.C., unless prepared by a Certified Public Accountant, the financial statement shall be signed in
the presence of a notary by the individual applicant.
SIGNATURE OF PREPARER: ______________________________________ Date: ______________

NOTARY SIGNATURE: ________________________________


NOTARY SEAL:



2010 August                                                Page 13 of 24                   ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application
                     Liability Insurance and Workers’ Compensation Affidavit

I have or will obtain, prior to contracting, worker’s compensation or an appropriate exemption as
provided in Section 440.05, Florida Statutes, and the required public liability and property damage
insurance as provided in Rule 61G6-5.008, Florida Administrative Code. Knowingly giving
misleading statements or misrepresentations when applying for a license constitutes a felony of
the third degree and may result in licensure denial or revocation. Under penalties of perjury, I
declare that I read the foregoing document and that the facts stated in it are true.

Applicant’s Signature:




                                   BUSINESS ENTITY AFFIDAVIT
         (NOT REQUIRED FOR THOSE APPLYING TO DO BUSINESS AS AN INDIVIDUAL)
(Please answer below according to your classification for the new business entity)

Are you designated as the Primary Qualifier?       Yes       No
If yes, pursuant to Chapter 489.522(1)(2)(a)(c), F.S., I attest that I will be legally and financially qualified
to act for this business entity and will have check approval authority for this business entity in all matters
connected with its contracting business.

Are you designated as the Secondary Qualifier?        Yes       No
If yes, pursuant to Chapter 489.522(b)(1)(2), F.S., I attest that I will be legally qualified to act for this
business as supervisor of all sites where permitting was obtained with my license. This includes any
other work for which I accept responsibility.

If requesting designation as a Secondary Qualifier or an Additional Primary Qualifier list the
current Primary Qualifier below.

Primary Qualifier Name: ___________________________ License Number: __________________


Print Applicant’s Name:


Applicant’s Signature:                                                         Date:

Note: if you are applying as secondary qualifier or additional primary qualifier - you are not
required to submit the following items: Business financial statement (page 16), Statement of bonding
or the irrevocable letter of credit (pages 17 & 18), Business credit report.



                                 STATEMENT OF FINANCIAL CONDITION

Are you applying to do business as an individual or sole proprietorship? If so please be aware as
an individual or sole proprietorship you may not be eligible for the worker’s compensation exemption –
please contact the Department of Financial Services, Division of Worker’s Compensation and determine
how you need to be licensed in order to qualify for the exemption.

Please indicate the type of business organization you are applying to qualify?

   Individual        Sole proprietorship        Corporation         Partnership           L.L.C.




2010 August                                        Page 14 of 24               ECLB Initial Certified License Application
   DBPR ECLB 4459 – Initial Certified License Application
                    FINANCIAL RESPONSIBILITY/BACKGROUND QUESTIONNAIRE
If you answer “yes” to any of the questions below, you must provide an explanation on the DBPR 0060–
General Explanatory Description form and attach legal documentation, i.e. satisfaction of lien, judgment,
payment schedule, etc.

The following persons must answer the financial responsibility questionnaire:
        Qualifying Agent, President, Vice-President, Secretary, Treasurer, Officers and Directors

Have you, or a partnership in which you were a partner, or an authorized representative, or a
corporation in which you were an officer or an authorized representative ever:

1. Undertaken construction contracts or work that a third party, such as a bonding or surety company,
   completed or made financial settlements for on your behalf?
2. Had claims or lawsuits filed for unpaid or past due accounts by your creditors?
3. Undertaken construction contracts or work that resulted in liens, suits or judgments being filed
   against you?
4. Had a lien of record filed against you by the U.S. Internal Revenue Service or Florida Corporate Tax
   Division or any other jurisdictions?
5. Made an assignment of assets in settlement of construction obligations for less than the debts
   outstanding?
6. Filed for bankruptcy voluntarily or involuntarily?
7. Been charged with, accused of, or investigated for acting as a contractor without a license?
8. Been convicted or found guilty of, or entered a plea of nolo contendere (regardless of adjudication)
   of any crime (other than a traffic violation)?
Indicate your response by circling Yes or No.         1         2     3       4        5        6         7        8
Qualifying Agent                   Print Name         Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
President                         Print Name          Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Vice President                   Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Secretary                        Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Treasurer                        Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Director or Member               Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Director or Member               Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No
Director or Member               Print Name           Yes       Yes   Yes     Yes      Yes      Yes       Yes      Yes
                                                      No        No    No      No       No       No        No       No




   2010 August                                  Page 15 of 24               ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application
                             BUSINESS FINANCIAL STATEMENT
Statement of Financial Condition Of: _______________________________________________
                                           (Name of Business Being Qualified, if applicable)
Date of Financial Statement:                                 FEID Number:
              ASSETS (Omit Cents)                             LIABILITIES (Omit Cents)
1. Cash in Bank                $                 14. Accounts Payable                $

2. Accounts and Notes          $                 15. Notes Payable to                $
Receivable                                       Banks and Others
                                                 (i.e., vehicles/equipment, etc…)
3. Inventory, i.e., supplies   $                 16. Mortgages and                   $
                                                 Bonds Payable
4. US Government               $                 17. Unpaid Taxes                    $
Securities
5. Other Current Assets,       $                 18. Wages & Interest                $
i.e., vehicles (itemize)
                               $                 19. Other Liabilities               $
                                                 (if corporation)
                               $

6. Real Estate                 $

7. Buildings-Net               $
(after depreciation)
8. Machinery, Fixtures &       $
Equipment
(after depreciation)
9. Leasehold                   $
Improvements-Net (after
amortization)
10. Cash Surrender Value       $
of Life Insurance
11. Stock & Bonds              $

12. Other Assets               $
(itemize)
                               $

13. Total Assets (add          $                 20. Total Liabilities               $
items 1 thru 12 above)                           (add items 14 thru 19
                                                 above)
                                                 21. Net Worth (Subtract             $
                                                 Item 20 from Item 13.)
                                                 TOTAL LIABILITIES/
TOTAL from Line 13             $                 NET WORTH – Add lines               $
                                                 20 and 21
    PLEASE NOTE THAT THE TOTAL ASSETS COLUMN AND TOTAL LIABILITIES/NET
               WORTH COLUMN MUST EQUAL THE SAME AMOUNT.

NAME AND SIGNATURE OF PREPARER: ______________________________________

Business Net Worth Requirements:
$10,000 for Certified Electrical, Certified Alarm I and Certified Alarm II Contractors
$5,000 for Certified Specialty Contractors

2010 August                                Page 16 of 24               ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application
                                    STATEMENT OF BONDING LIMITS

Qualifying (Applicant) Agent's Name:_____________________________________________________

Business Entity's Name:________________________________________________________________

Board Rule 61G6-5.004(1), F.A.C., requires that you submit a statement signed and sealed by an officer
of a Florida licensed surety company that the surety company would issue a performance or payment
bond in the amount of $25,000 for an unlimited electrical contractor or alarm system contractor and
$10,000 for a specialty contractor. You may substitute an irrevocable letter of credit from a responsible
financial institution in the same amounts, in lieu of this requirement. (The letter is on the next page.)

SURETY AGENT COMPLETES THIS SECTION:

1.      Attach an original "Power of Attorney" certifying that said power of attorney appointed is in full
        force and effect.
2.      Have signature of officer of surety company notarized.
3.      Date surety company was licensed to do business in the State of Florida.
4.      This statement of bonding limits represents the bondability of the named business entity based
        on its current financial condition and is submitted for the purpose of licensure of the business
        entity.

This is a statement that the business entity is bondable and the surety agent would issue a performance
or payment bond for the business entity in an amount of $25,000 for an unlimited electrical contractor and
alarm system contractor or $10,000 for a specialty contractor.

The business entity noted above is qualified to be bonded with (Name of Surety Agent)



and we would issue a performance or payment bond in the amount of:

(PLEASE CIRCLE AMOUNT) $25,000 or $10,000 (See note above when determining amount.)



Signature-Officer of Surety Agent                              Print Name of Officer


Date licensed to do business in Florida                           and License #


SURETY COMPANY SEAL:




2010 August                                    Page 17 of 24             ECLB Initial Certified License Application
DBPR ECLB 4459 – Initial Certified License Application

                              CLEAN IRREVOCABLE LETTER OF CREDIT
              (**USED TO IN PLACE OF STATEMENT OF BONDING LIMIT IF STATEMENT OF
                                BONDING LIMIT IS NOT AVAILABLE**)

Issuing Branch:________________________________________________________________________

Address:______________________________________ Phone Number:___________________________

Date of Issuance:_______________________________ Credit Number:____________________________

Expiration Date:_________________________________________

(Time frame of irrevocable letter of credit)
(Drafts must be presented before close of business this date)
BENEFICIARY NAME AND ADDRESS                             APPLICANT NAME, BUSINESS AND ADDRESS

State of Florida
DBPR – ECLB
1940 North Monroe Street
Tallahassee, FL 32399-0771
MAXIMUM AMOUNT (IN WORDS)
U.S. $

To Whom It May Concern:

We hereby establish our Clean Irrevocable Letter of Credit #                                          in your
favor for the account of the above applicant to the extent of the face amount of this Letter of Credit which
shall not exceed U.S.                                   . We undertake to honor your drafts not exceeding in
the aggregate the amount of this Letter of Credit referenced above at sight on us at our office designated
above. The total amount of this Letter of Credit is available from the date hereof against presentation of
your sight draft(s) if presented to the issuing branch.

Draft(s) drawn under this Letter of Credit must bear the clause:


"Drawn under                                       & Trust Company,                                      Branch
Irrevocable Letter of Credit No.                                   , dated                                     ."

Partial drawings are permitted hereunder.
All amounts drawn hereunder must be endorsed on the reverse hereof by the negotiating party.

Except as otherwise expressly stated herein, this Letter of Credit is subject to the "Uniform Customs and
Practices for Documentary Credits" (International Chamber of Commerce Brochure No. 500, 1998 version).

Yours very truly,


Bank & Trust Company:

By:                                                        Title: ____________________________________




2010 August                                     Page 18 of 24                ECLB Initial Certified License Application
DBPR 0010 – Master Individual Application                                                                      page 1 of 3

                                                 STATE OF FLORIDA
                                            DEPARTMENT OF BUSINESS AND
                                             PROFESSIONAL REGULATION

                                                 PERSONAL INFORMATION
 Social Security Number*

 Last Name                                          First                         Middle               Title               Suffix

 Birth Date (MM/DD/YYYY)                                             Gender
                                                                     Male   Female
 Race/Ethnicity (check only one):
   Black or African American                    Asian or Pacific Islander                Native American or Alaskan Native
   White or Caucasian                           Spanish, Hispanic or Latino              Other
                                                     MAILING ADDRESS
 Street Address or P.O. Box



 City                                                                           State                  Zip Code (+4 optional)

 County (if Florida address)                                         Country

                                                 CONTACT INFORMATION
 Primary Phone Number                         Primary E-Mail Address

                       RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
 Street Address



 City                                                                           State                  Zip Code (+4 optional)

 County (if Florida address)                                         Country

                                             BUSINESS LOCATION ADDRESS
 Business/Firm Name

 Street Address



 City                                                                           State                  Zip Code (+4 optional)

 County (if Florida address)                                         Country



                       ADDITIONAL CONTACT INFORMATION (OPTIONAL)
 Alternate Phone Number                      Fax Number

 Alternate E-Mail Address

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In
this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections
455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also
be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.




     2010 August                                                Page 19 of 24                   ECLB Initial Certified License Application
DBPR 0010 – Master Individual Application                                                                       page 2 of 3

                                      PRIOR LICENSE INFORMATION
 If you currently or previously have held a business or professional license/registration in Florida or
 elsewhere, please list them below:
 1. License/Registration Type         State              Date (From)                 Date (To)

 License Number                                                      Name Used

 2. License/Registration Type                 State                  Date (From)                       Date (To)

 License Number                                                      Name Used

 3. License/Registration Type                 State                  Date (From)                       Date (To)

 License Number                                                      Name Used


                                               BACKGROUND INFORMATION
  1.            Yes            No        Have you ever been convicted of a crime, found guilty, or entered a plea of guilty
           (If yes, please               or nolo contendere (no contest) to, even if you received a withhold of
           complete form                 adjudication? This question applies to any violation of the laws of any municipality,
               0050-1)                   county, state or nation, including felony, misdemeanor and traffic offenses (but not
                                         parking, speeding, inspection, or traffic signal violations), without regard to
                                         whether you were placed on probation, had adjudication withheld, were paroled,
                                         or pardoned. If you intend to answer “NO” because you believe those records
                                         have been expunged or sealed by court order pursuant to Section 943.058,
                                         Florida Statutes, or applicable law of another state, you are responsible for
                                         verifying the expungement or sealing prior to answering "NO." YOUR ANSWER
                                         TO THIS QUESTION WILL BE CHECKED AGAINST LOCAL, STATE AND
                                         FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION ACCURATELY
                                         MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IF YOU
                                         DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN
                                         ATTORNEY OR CONTACT THE DEPARTMENT.
  2.            Yes            No        Has any judgment or decree of a court been entered against you in this or any
           (If yes, please               other state, province, district, territory, possession or nation, in which you were
           complete form                 charged in the petition, complaint, declaration, answer, counterclaim, or other
               0050-1)                   pleading with any fraudulent or dishonest dealing, or is there any such case or
                                         investigation pending?
  3.            Yes            No        Have you ever had an application for registration, certification, or licensure in
           (If yes, please               Florida or in any other jurisdiction denied, or is there now pending a proceeding or
           complete form                 investigation to deny such an application?
               0060-1)
  4.            Yes            No        Has any license, registration or permit to practice any regulated profession,
           (If yes, please               occupation, vocation, or business been revoked, annulled, suspended,
           complete form                 relinquished, surrendered, or withdrawn in Florida or in any other jurisdiction, or is
               0060-1)                   any such proceeding or investigation now pending?
If you answered “YES” to questions 1 – 4 above, please provide the full details of any criminal conviction, lawsuit or judgment, or
administrative action including the nature of any charges, dates, outcomes, sentences, and/or conditions imposed; the dates, name and
location of the court and/or jurisdiction in which any proceedings were held or are pending; and the designation and/or license number
for any actions against a license or licensure application. Please utilize form 0050-1 for your responses to questions 1 and 2, and form
0060-1 for your responses to questions 3 and 4. If you have more than seven offenses to document on form 0050-1, attach additional
copies of form 0050-1 as necessary.

                                       PRIOR NAME INFORMATION
 Have you used, been known as, or called by another name (example - maiden name, pseudonym,
 nickname) or alias other than the name signed to the application? Yes       No
 If your answer is yes, state name or names used below:
 Last Name                               First                    Middle     Title        Suffix

 Last Name                                          First                          Middle              Title                Suffix

 Last Name                                          First                          Middle              Title                Suffix


       2010 August                                              Page 20 of 24                   ECLB Initial Certified License Application
DBPR 0010 – Master Individual Application                                                       page 3 of 3

                                            ATTEST STATEMENT
 I have read the questions in this application and have answered them completely and truthfully to
 the best of my knowledge.

 I have successfully completed the education, if any, required for the level of licensure,
 registration, or certification sought.

 I have the amount of experience required, if any, for the level of licensure, registration, or
 certification sought.

 I pledge to comply with the applicable standards of practice upon licensure, registration, or
 certification.

 I understand the types of misconduct for which disciplinary proceedings may be initiated.

 Giving knowingly misleading statements or knowing misrepresentation when applying for a
 license constitutes a felony of the third degree and may result in licensure denial or revocation.

 Under penalties of perjury, I declare that I have read the foregoing document and that the facts
 stated in it are true.

 Signature:

 Print Name:

 Social Security Number:




    2010 August                                       Page 21 of 24              ECLB Initial Certified License Application
DBPR 0020 – Master Organization Application

                                                             STATE OF FLORIDA
                                                        DEPARTMENT OF BUSINESS AND
                                                         PROFESSIONAL REGULATION




                                ORGANIZATION INFORMATION
Federal Employer ID Number/Social Security Number*

Organization/Applicant Name

Doing Business As (D/B/A) Name

Ownership: Proprietorship Corporation Partnership Joint Venture Agreement
            Trust Agreement Estate Professional Association Other
                                     MAILING ADDRESS
Street Address or P.O. Box



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country

                                                                 CONTACT INFORMATION
Contact Name

Primary Phone Number                                        Primary E-Mail Address

                              RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country

                                                           BUSINESS LOCATION ADDRESS
Street Address



City                                                                                                    State                           Zip Code (+4 optional)

County (if Florida address)                                                               Country



                      ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number                      Fax Number

Alternate E-Mail Address

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are
mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers
must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.




2010 August                                                                    Page 22 of 24                              ECLB Initial Certified License Application
DBPR 0050 – Explanatory Information for Background Questions                                      page 1 of 1

                                      STATE OF FLORIDA
                              DEPARTMENT OF BUSINESS AND
                                PROFESSIONAL REGULATION
                        NOTE – This form must be submitted as part of an
                                       application packet

                                        PERSONAL INFORMATION
Last Name                                 First            Middle                Title                Suffix

Identify question number on form DBPR 0010 this explanation pertains to:



                                            EXPLANATION
Offense

County                                               State

Penalty/Disposition

Date of Offense (MM/DD/YYYY)                         Have all sanctions been satisfied?
                                                     Yes             No
Description




                                            EXPLANATION
Offense

County                                               State

Penalty/Disposition

Date of Offense (MM/DD/YYYY)                         Have all sanctions been satisfied?
                                                     Yes             No
Description




Attach additional sheets as necessary




2010 August                                   Page 23 of 24            ECLB Initial Certified License Application
DBPR 0060 – General Explanatory Description                                               page 1 of 1

                                   STATE OF FLORIDA
                           DEPARTMENT OF BUSINESS AND
                             PROFESSIONAL REGULATION
                     NOTE – This form must be submitted as part of an
                                    application packet

                                 APPLICANT INFORMATION
Last Name                          First            Middle               Title                Suffix



                                      EXPLANATION




2010 August                             Page 24 of 24          ECLB Initial Certified License Application

								
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