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: State of Florida
Department of Business and Professional Regulation
Electrical Contractors Licensing Board
Application for Certification of Registered Electrical, Alarm or Specialty Contractor
By Grandfathering
Form # DBPR ECLB 13
APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.
APPLICATION REQUIREMENTSALL License Applicants must submit:
Fees:
If applying for Inactive status- $205.
If applying for Active status- $205.
If applying to grandfather Additional Business Qualification - $205.
*Note all registered licenses in the same category must be grandfathered at the same time.
Make check payable to the Florida Department of Business and Professional Regulation.
Credit report on the applicant from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state, and federal levels. For a list of acceptable agencies visit http://www.myfloridalicense.com/dbpr/pro/cilb/documents/cilb_credit_reporting_agencies.pdf.
Supporting legal documentation, if necessary. See Sections 2(i-k) of Instructions.
Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if applicable.
ACTIVE License Applicants must also submit:
If qualifying a business-
Credit report on the business to be qualified from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state, and federal levels. For a list of acceptable agencies visit http://www.myfloridalicense.com/dbpr/pro/cilb/documents/cilb_credit_reporting_agencies.pdf
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Rd.
Tallahassee, FL 32399-0783
Note: All Grandfathering applications must be postmarked on or before November 1, 2021. Applications postmarked after this date will not be processed.
INSTRUCTIONS
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.
General Requirements for Grandfathering
Applicants must be at least 18 years of age, be of good moral character, meet the requirements, and pay all applicable fees.
This form is required if you are applying to become a Certified Electrical, Alarm or Electrical Specialty Contractor by grandfathering.
Applicant must have held an active Registered Electrical, Alarm or Specialty license with the Electrical Contractors Licensing Board for at least five (5) years at the time of application or
Applicant must hold a Registered Electrical, Alarm or Specialty license with the Electrical Contractors Licensing Board and have held an active Electrical Inspector or Building Code Administrator license for at least five (5) years, with oversight in the category being applied for.
Applicant must have taken and passed a written proctored examination.
Applicants whose license(s) were revoked at any time, suspended within the last five (5) years or were assessed a fine in excess of $500 within the last five (5) years, are NOT eligible to apply for certification through grandfathering. Also, any time a license was on probation shall not count toward the five (5) years of active licensure.
Application Instructions (by section)
Section I- Application Type
Select the transaction requested and license category you are applying to grandfather. An active license will allow you to perform work as an Electrical, Alarm or Specialty Contractor, an inactive license cannot be used for contracting.
Please list the license number of your Registered Electrical, Alarm or Specialty license and date it was issued in the space provided. When your certified license is issued your registered license(s) in the same category will be cancelled.
Section II - Applicant Personal Information
Fill out each section completely. A Social Security number is required to apply for any individual license within the Department of Business and Professional Regulation.
In the Full Legal Name section provide your full legal name as it appears on your Social Security card. Do not use any nicknames or initials. Please list any aliases or prior names in the prior name information section.
Provide your mailing address. This will be used for sending correspondence regarding your application and license.
Contact information is often used to quickly resolve questions with applications by telephone call or email. If contact information is not provided, questions regarding applications will be mailed to the applicants mailing address and may take longer to resolve.
Additional contact information is optional and will be used when the applicant cannot be reached using their primary contact information.
Applicants must provide information on current or prior licenses held in Florida or any other state, territory, or jurisdiction of the United States or in any foreign national jurisdiction.
Applicants must provide information on any prior names or aliases used by applicant. If the name on supporting documentation does not match the applicants legal name, the alias used in the supporting documentation must be provided in this section. Failure to do so will result in a deficient application.
Section III Qualification for Licensure
Please indicate which requirement you qualify under by checking the appropriate box.
Section IV Business to be Qualified Information
Complete this section entirely.
Provide the name of the business to be qualified as it is registered with the Florida Division of Corporations.
The Doing Business As (D/B/A) name must be provided as it is registered with the Florida Division of Corporations, if the business uses a fictitious name to conduct business.
Applicants must provide the Federal Employer Identification Number (FEID) for the business to be qualified. Please be aware that as an individual or sole proprietorship you may not be eligible for the workers compensation exemption please contact the Department of Financial Services, Division of Workers Compensation and determine how you need to be licensed in order to qualify for the exemption.
Applicants must provide the business location address of the business to be qualified.
Section V Liability Insurance and Workers Compensation
Applicant must answer questions 1 and 2 in this section. Applicant is required to obtain the required insurance as listed on the application and workers compensation coverage. Information regarding workers compensation insurance and exemptions is available by contacting the Department of Financial Services, Division of Workers Compensation. If applying for Inactive Status this section does not need to be completed.
Section VI Statement of Financial Condition
Please mark the box that accurately reflects the type of business you are applying to qualify.
Section VII Qualifier Information
If the applicant is a primary qualifier he/she is required to have financial and supervisory authority for the business. Without this authority an applicant will not be approved.
Applicants must state whether the business to be qualified is already qualified by another contractor. If so, provide the qualifying contractors name and license number in the spaces provided.
If the applicant is a secondary qualifier he/she must have supervisory authority over all sites where their license is used to pull the permit. An applicant cannot apply to be a secondary qualifier unless there is a licensed Electrical/Alarm or Electrical Specialty contractor already designated as a primary qualifier for the business.
Secondary qualifiers will automatically become primary qualifiers if the primary qualifier ceases qualifying the business and a new primary qualifier is not designated within 60 days.
Section VIII Business Financial Statement
The business financial statement must be prepared within twelve (12) months preceding the 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
All vehicles and real property listed as assets of the business must be titled to the business to be considered assets of the business. DO NOT include personal vehicles and property as assets of the business.
Applicant should list all of the business assets and liabilities on the form.
Total value of assets listed should be listed in Box 12.
Total value of liabilities listed should be listed in Box 19.
To determine net worth (Box 12 - Box 19 = Net Worth)
List net worth in Box 20. The business net worth should be at least $10,000 for Certified Electrical, Certified Alarm I and Certified Alarm II Contractors or $5,000 for Certified Specialty Contractors. A business net worth that does not meet minimum requirements is considered grounds for denial.
Section IX Background Questions
The applicant and the authorized representative(s), as specified in the section, must submit answers to each of the background questions.
For each Yes answer the person must provide an explanation in Section X or XI, as applicable.
The number of Yes boxes checked must equal the number of explanation boxes completed.
If you answered YES to any question, please provide full explanations as required below. If you have more than two offenses to document in Section X or more than two in Section XI, attach additional copies as necessary.
Section X Explanations for Yes answers to Question 1
For this section, provide as much detail as possible.
Each explanation can only relate to one person and one question.
Question 1:
If you answer yes to this question, you must complete Section X [make additional copies as necessary] of the application. Please provide the full details of the criminal charges including 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. If you answer NO to this question because you believe that previous incidents have been dismissed, no action taken, nolle prossed, or expunged, you must supply documentation as proof of the disposition or showing sanctions were satisfied.
Section XI Explanations for Yes answers to Questions 2-6
Question 2:
If you answer yes to this question, you must complete Section XI [make additional copies as necessary] of the application and you must also supply documentation proving the bankruptcy has been discharged or the judgment or lien has been satisfied, or if not, stating the current status of the bankruptcy, judgment or lien.
Question 3:
If you answer yes to this question provide the full details in Section XI explaining the denial or pending 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.
Question 4:
If you answer yes to this question provide the full details explaining the situation in Section XI 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
Question 5:
If you answer yes to this question provide the full details in Section XI explaining the situation and provide copies of any relevant documentation.
Question 6:
If you answer yes to this question provide the full details in Section XI explaining the situation and provide copies of any relevant documentation.
Section XII Verification of Examination and Letter of Good Standing
Both sections of this page must be completed in their entirety and signed by a Building or Licensing Official or Designee from the county/city in which you hold a local competency card. You can have the Verification of Examination section completed by one county and Letter of Good Standing completed by another county if you are no longer licensed in the county where you took the examination.
Section XIII- Affirmation by Written Declaration
Please read and sign the affirmation by written declaration.
If the applicant fails to sign the affirmation statement, the Department will not process the application.
Additional Supporting Documentation Required
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/cilb/documents/cilb_credit_reporting_agencies.pdf for a list of acceptable agencies.
If there are negative items on the credit report such as open collections, past due accounts, foreclosures or bankruptcy please provide a written explanation of the issue and the current status of those items.
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/cilb/documents/cilb_credit_reporting_agencies.pdf for a list of acceptable agencies.
If there are negative items on the credit report such as open collections, past due accounts, foreclosures or bankruptcy please provide a written explanation of the issue and the current status of those items.
Common Reasons for Denial
Your application could be denied for many reasons even if you have passed the examination. Here are some of the more common reasons for denial:
Examination - Failure to provide proof having taken and passed an examination is a basis for denial.
5 years as a Registered Contractor - Not having held an active registered license for at least 5 years is a basis for denial.
Discipline - Having had your license revoked at any time, suspended within the last five (5) years or having been assessed a fine in excess of $500 within the last five (5) years are all basis for denial.
Failure to demonstrate financial responsibility There could be a basis for denial based on your personal credit report. This may occur if your personal credit report shows delinquent accounts, collection accounts, unpaid liens or judgments.
Criminal history that relates to the practice of electrical contracting - If you have criminal history you must disclose it in your application it will be up to the Board to determine if it relates to the practice of electrical contracting and if it is sufficient grounds to deny your application.
State of Florida
Department of Business and Professional Regulation
Electrical Contractors Licensing Board
Application for Certification of Registered Electrical, Alarm or Specialty Contractor
By Grandfathering
Form # DBPR ECLB 13
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.
For additional information see the Instructions at the beginning of this application.
Section I Application Type
CHECK TRANSACTION REQUESTEDInitial Certification of Registered Contractor (Active) - $205.00 fee required [1022]
Initial Certification of Registered Contractor (Inactive) - $205.00 fee required [1036]
Certification of Registered Additional Business Qualification (Active) - $205.00 fee required [1026]CHECK LICENSE CATEGORYUnlimited 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]Please list the license number you are grandfathering with this application and date of licensure:
Note: If you hold any additional business qualifications you must submit a separate application to grandfather each of them. You must grandfather all registered licenses in a category at the same time.
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(s) and they will be cancelled.
*Note all registered licenses in the same category must be grandfathered at the same time.
Section II Applicant Personal Information
PERSONAL INFORMATIONSocial Security Number*FULL LEGAL NAME Last Name First Middle Title SuffixBirth Date (MM/DD/YYYY)
/ /Gender
( Male ( Female MAILING ADDRESSStreet Address or P.O. BoxCityStateZip Code (+4 optional)County (if Florida address)CountryCONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited by the authority granted by 42 U.S.C. 653 and 654, and will be used by the Department of Business and Professional Regulation pursuant to 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by 559.79(1), Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. 405(c)(2)(C)(i), to be used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
Section II Applicant Personal Information continued
ADDITIONAL CONTACT INFORMATION (OPTIONAL)Alternate Phone NumberFax NumberAlternate E-Mail Address CURRENT/PRIOR LICENSE INFORMATIONIf you currently hold or have previously held a business or professional license/registration in Florida or elsewhere, please list each one below (attach additional copies of this page as necessary):1. License/Registration TypeStateDate (From)
/ /Date (To)
/ /License NumberName Used2. License/Registration TypeStateDate (From)
/ /Date (To)
/ /License NumberName Used3. License/Registration TypeStateDate (From)
/ /Date (To)
/ /License NumberName UsedPRIOR NAME INFORMATIONHave you used, been known as, or are currently known by another name (example - maiden name, 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 SuffixLast Name First Middle Title SuffixLast Name First Middle Title Suffix
Section III Qualification for Licensure
QUALIFICATION FOR LICENSUREA person shall be eligible for licensure by meeting one of the following requirements. (Check one)
NOTE: If your license was revoked at any time, suspended within the last five (5) years or has been assessed a fine in excess of $500 within the last five (5) years, you are NOT eligible to apply for certification. Also, years a license was on probation shall not count toward the five (5) years of active licensure.Has held an active Registered Electrical, Alarm or Specialty license with the Electrical Contractors Licensing Board for at least five (5) years at the time of application and has taken and passed a written proctored examination.
Holds an inactive Registered Electrical, Alarm or Specialty license with the Electrical Contractors Licensing Board and has held an active Electrical Inspector or Building Code Administrator license for at least five (5) years with oversight in the category you are applying for and took and passed a written proctored examination.
Electrical Inspector or Building Code Administrator License Number: _____________________________
Section IV Business to be Qualified Information
BUSINESS TO BE QUALIFIED
Note: Do not complete this section if you are applying for licensure as an individual. You will, however, be required to complete this form if you are applying for licensure as a sole proprietor. See 2(d) of instructions.
*Business Name:*Doing Business As (D/B/A):Federal Employer ID Number (FEID):* Business Name and D/B/A must be listed exactly as registered with the Division of Corporations.
If you list both a Business Name and a D/B/A, only the D/B/A will appear on the license.BUSINESS CONTACT INFORMATION Contact Name:Phone Number of ContactE-Mail Address of ContactBUSINESS LOCATION ADDRESS Street AddressCityStateZip Code (+4 optional)County (if Florida address)Country
Section V Liability Insurance and Workers Compensation
LIABILITY INSURANCE AND WORKERS COMPENSATION
Minimum amounts required for Liability insurance;
Public Liability- $100,000/per person, $300,000/per occurrence; and Property Damage- $500,000.
OR
Minimum combined single limit policy of $800,000.
Have you or will you obtain, prior to contracting, public liability and property damage insurance in the amounts determined by Rule 61G6-5.008, Florida Administrative Code, as specified above?
( Yes ( No
Have you or will you obtain, prior to contracting, workers compensation or an appropriate exemption as provided in Section 440.05, Florida Statutes, and if not, do you attest that you will obtain an exemption within 30 days after your license is issued?
( Yes ( No
Section VI Statement of Financial Condition
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 workers compensation exemption please contact the Department of Financial Services, Division of Workers 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 ( LLC ( Other
Section VII Qualifier Information
QUALIFIER INFORMATION
(NOT REQUIRED FOR THOSE APPLYING TO DO BUSINESS AS AN INDIVIDUAL)(Please answer below according to your classification for the new business entity)( I am requesting designation as Primary Qualifier:
Pursuant to Chapter 489.522(1)(a), F.S.: I have the authority for approving checks, payments, drafts and contracts on behalf of the business organization.( Yes ( No I am responsible for supervision of all operations of the business organization; including, all field work at all sites and financial matters (both in general and for each specific job).( Yes ( No ( I am requesting designation as Secondary Qualifier:
Pursuant to Chapter 489.522(2)(b), F.S.:I will be legally qualified to act for this business as supervisor of all sites where permitting was obtained with my license, and any other work for which I accept responsibility.( Yes ( No If requesting designation as a Secondary Qualifier or an Additional Primary Qualifier list the Primary Qualifier below.Primary Qualifier Name:Primary Qualifiers License Number:
Note: If you are applying as secondary qualifier or additional primary qualifier and the current primary qualifier is certified in the same category you are not required to submit the following items: business financial statement; or business credit report.
Section VIII Business Financial Statement
BUSINESS FINANCIAL STATEMENT
See Section 2(h) of instructions.
Note: If you are applying as an Individual this form should be completed as a personal financial statement.
Statement of Financial Condition of : ______________________________________________________
(Name of Business Being Qualified)Date of Financial Statement: FEID Number:ASSETS (omit cents)LIABILITIES (omit cents)1. Cash in Bank$13. Accounts Payable$2. Accounts and Notes Receivable$14. Notes Payable to Banks and others (i.e., vehicles/equipment, etc)$
3. Inventory, (i.e. Supplies)$15. Mortgages and Bonds Payable$4. US Government Securities$16. Unpaid Taxes$5. Other Current Assets, i.e. vehicles (itemize)$17. Wages & Interest$
$18. Other Liabilities (if corporation)$
$$6. Real Estate$$7. Buildings-Net (after depreciation)$$8. Machinery, Fixtures & Equipment (after depreciation)$$9. Leasehold Improvements-Net (after amortization)$$
$$10. Stocks & Bonds
$$11. Other Assets (itemize)
$$
$$12. Total Assets (add items 1 thru 11 above)$19. Total Liabilities (add items 13 thru 18 above)$
20. Net Worth (subtract item 19 from item 12)$
Business Net Worth Requirements:
$10,000 for Certified Electrical, Certified Alarm I and Certified Alarm II Contractors
$5,000 for Certified Specialty Contractors
NOTE: All vehicles and real property listed as assets of the business must be titled to the business to be considered assets of the business. Please DO NOT include personal vehicles and property as assets of the business.
Section IX Background Questions
BACKGROUND QUESTIONS
Instructions:The Applicant and Authorized Representative(s) of the business must answer the background questions in this section.
Authorized Representative(s) of the business are any of the following:
All officers and directors (if qualified business is a corporation or any other business entity with officers and directors)
All members and managers (if qualified business is a LLC)
All partners (If qualified business is a partnership)
All members (if qualified business is a business entity other than those described above)
NOTE: Accuracy of Authorized Representative(s) of the business may be checked on the Florida Division of Corporations website www.sunbiz.org.If YES to question 1, please complete Section X.
If YES to questions 2 through 6, please complete Section XI.1. Have you ever been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a crime in any jurisdiction, or are you currently under criminal investigation? This question applies to any criminal violation of the laws of any municipality, 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 943.0585 or 943.059, 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. Have you ever filed for bankruptcy (voluntarily or involuntarily) or had any judgment or lien against yourself, a business you previously qualified, or the business you are applying to qualify? This question applies to any unpaid judgments or liens, including those for unpaid past-due bills by creditors, construction and non-construction issues, and tax liens. Explanations for this answer must be completed in Section XII. Use your credit report as a guide when answering this question.3. Have you ever had a license revoked, suspended, or otherwise sanctioned by any professional licensing board or agency, or have you ever been denied issuance of, or pursuant to disciplinary proceedings refused renewal of a license by any professional licensing board or agency in Florida or any other state?4. Have you ever been charged with acting as a contractor without a license?5. Have you 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?6. Have you ever made an assignment of assets in settlement of construction obligations for less than the debts outstanding?Person #Indicate each response by checking Yes or NoQuestion Number1234561Applicant Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No2Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No3Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No4Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No
Section IX Background Questions continued
Person #Indicate each response by checking Yes or NoQuestion Number1234565Authorized Representative Print Name(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No6Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No7Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No8Authorized Representative Print Name
(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No(Yes
(No
If you answered YES to any question in questions 1 6 above, please refer to the Instructions for detailed information on providing complete explanations, including requirements for submitting supporting legal documents. Please complete Section X for your response to question 1, and complete Section XI for your response to questions 2 through 6. If you have more than two offenses to document in Section X or need additional sheets for Section XI, attach additional pages as necessary.
Section X Explanations for Yes answers to Question 1 Attach additional copies as necessary
EXPLANATION Name of person to whom this explanation relates:Offense:County:State:Date of Offense (mm/dd/yyyy):Penalty/ Disposition:Have all sanctions been satisfied?
( Yes ( NoDescription:
EXPLANATION Name of person to whom this explanation relates:Offense:County:State:Date of Offense (mm/dd/yyyy):Penalty/ Disposition:Have all sanctions been satisfied?
( Yes ( NoDescription:
Section XI Explanations for Yes answers to Questions 2-6 Attach additional copies as necessary.
Review your credit report and, if applicable, be sure to provide explanations of all negative items such as collections, liens, judgments and foreclosures. Also, provide documentation showing release of liens, discharge of bankruptcy and satisfaction of judgments. Application processors will be looking for explanations to negative items listed on your credit report in this section. Use your credit report as a guide when providing your answers.
EXPLANATIONName of person to whom this explanation relates:This explanation relates to question # (check one):
( 2 ( 3 ( 4 ( 5 ( 6State/Jurisdiction: Application Type/License Number:
EXPLANATIONName of person to whom this explanation relates:This explanation relates to question # (check one):
( 2 ( 3 ( 4 ( 5 ( 6State/Jurisdiction: Application Type/License Number:
Section XII Verification of Examination and Letter of Good Standing
VERIFICATION OF EXAMINATION AND LETTER OF GOOD STANDINGThis page must be completed by a Building or Licensing Official or Designee
(This form may be duplicated in order to submit the letter of good standing separate from the examination verification letter.)
APPLICANT INFORMATION
Last Name First Middle Title Suffix
Birth Date (MM/DD/YYYY)
/ /
Registered License Number
VERIFICATION OF EXAMINATION
This is to certify that the above named licensee has taken and passed the examination detailed below.
Examination Category:
Examination Passing Date:
Examination Provider Please check one
( National Assessment Institute
( Block and Associates
( NAI/Block
( H. H. Block
( Experior Assessments
( Professional Testing, Inc.
( Assessment Systems, Inc.
( Thomson Prometric
( GTS-GITS Gainesville IND Testing Service
( PSI
( Other Exam Provider: _______________________________________
LETTER OF GOOD STANDING
This is to certify the above named licensee holds a license in good standing with this county/city. There are no pending complaints against the licensee and no disciplinary actions have been taken against the licensee in the past five (5) years by this county.
Signature of Building/Licensing Official or Designee: (Name of Building/ Licensing Official or Designee)
VERIFICATION BY BUILDING OR LICENSING OFFICIAL OR DESIGNEE
This section should be completed by the Building of Licensing Department employee who is verifying the examination and license in good standing for the above named licensee.
Print Name of Building/Licensing Official or Designee: (Name of Building/ Licensing Official or Designee)
Title of Building/Licensing Official or Designee:
(Title)
Signature of Building/Licensing Official or Designee: (Signature)
Name of County or Municipality: ________________________________________
(County or Municipality)
Building and Licensing Departments do not leave any blanks on this form.
Please put N/A in any sections you cannot complete. Section XIII Affirmation by Written Declaration
AFFIRMATION BY WRITTEN DECLARATIONI certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license.
Signature:Date:Print Name:
Make sure you submit the following items with your application:Personal Credit Report from a nationally recognized credit reporting agency
Business Credit Report from a nationally recognized credit reporting agency
Itemization of machinery, fixtures & equipment and other assets listed on business financial statement.Application Tip:When completing the financial questions on your application, use your credit reports as a guide. Make sure to provide explanations of all negative items such as collections, liens, judgments and foreclosures in Section XI. Copy this page as necessary. Also, provide documentation showing release of liens, discharge of bankruptcy and satisfaction of judgments. Processors will be using your credit report as a guide to your answers regarding financial questions.
Note: All Grandfathering applications must be postmarked on or before November 1, 2021. Applications postmarked after this date will not be processed.
PAGE 4 of NUMPAGES 15
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