ࡱ> '` HhbjbjLULU <.?.?_8$  h((P(xxx"ֳ V X X X X X X $?hz| ûûû| xx4 ûxxV ûV 2x PR^<".< 0 P!'!\!8 vl,+| | Ed ûûûû$ Sh]O h] State of Florida Department of Business and Professional Regulation Electrical Contactors Licensing Board Application for Registered Electrical, Alarm System or Specialty Contractor Transactions Form # DBPR ECLB 3 APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. QUALIFICATIONS: Registration of Electrical, Alarm System and Specialty Contractors Registration of local license for counties/cities that require examination: If the county/city requires successful completion of an examination prior to issuance of a competency card, the competency card can be registered with the state without additional examination requirements. APPLICATION REQUIREMENTSALL License Applicants must submit: Fees: Initial Registration- $155. Initial Registration in Inactive status- $55. Additional County Registration- $25. Additional Business Registration- $155. Reactivation of Registered License- $120. Transfer of Registered License- $50. Make check payable to the Florida Department of Business and Professional Regulation. Submit a copy of your current local competency card. Submit proof of examination for initial registration only. Supporting legal documentation, if necessary. See Item 2(h and i) of Instructions. Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if applicable. Reactivation of Registered License Applicants must also submit: Proof of completion of 14 hours of continuing education.  Please mail your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0783 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 Registration This form is required if you are applying to get an initial registered license, transfer a registered license to a new business, qualify an additional business, add a county or reactivate an inactive license. You must have a current competency card in order to become a registered electrical, alarm or specialty contractor. Application Instructions (by section) Section I- Application Type Select the transaction you wish to conduct. An active license will allow you to perform work as an electrical/alarm or specialty contractor, an inactive license cannot be used for contracting. Select the category and the county or counties that you request to register. 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 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 contact the HYPERLINK "http://www.myfloridacfo.com/wc/"Department of Financial Services, Division of Workers Compensation. Section IV 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 permit the work performed. 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 V 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  HYPERLINK "http://www.myfloridacfo.com/wc/" Department of Financial Services, Division of Workers Compensation and determine how you need to be licensed in order to qualify for the exemption. If this application is to qualify an additional business please indicate the % of ownership you have in the business or businesses you already qualify and in the business you are requesting to qualify. Applicants must provide the business location address of the business to be qualified. Section VI Business Entity Transfer Complete this section only if you are transferring your license to a new business. Completion of this section will end your status as qualifier of your current business. Section VII 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 VIII or IX, 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 VIII or more than two in Section IX, attach additional copies as necessary. Section VIII 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 VIII [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 IX Explanations for Yes answers to Questions 2-6 Question 2: If you answer yes to this question, you must complete Section IX [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 IX 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 in Section IX explaining the situation 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 IX 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 IX explaining the situation and provide copies of any relevant documentation. Section X- Affirmation by Written Declaration The applicant must read and sign the affirmation by written declaration. Additional supporting documentation Required Copy of current competency card. For initial registration you must submit proof of examination. Effective July 1, 2012, in order to reactivate an inactive license, you will need to completethe continuing education requirements in place at the time of the last renewal for your profession. That includes 14hours of board-approved continuing education that was taken during the last, or current, renewal period and must include the following: 7 hours of Technical, 1 hour Workers Compensation, 1 hour Business Practices, 1 hour Florida Building Code advanced module course, 1 hour Workplace Safety and 2 hours False Alarm Prevention for Alarm contractors and ECs who work on alarms. Common Reason for Denial 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 Contactors Licensing Board Application for Registered Electrical, Alarm System or Specialty Contractor Transactions Form # DBPR ECLB 3 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 end of this application. Section I Application Type CHECK TRANSACTION REQUESTEDInitial Registration Application - $155 fee required [1030]Registration Application for Additional County- $25 fee[3022]Registration Application for Additional Business- $155 fee [1030] (*Note: Applicants will be required to attend the Board Meeting when their additional business application is reviewed, you will receive a letter with the date, time and location of the meeting.)Request for Reactivation of a Registered License- $120 fee [3020]Initial Inactive Registered License- $55 fee [1031]Request for Transfer of a Registered License- $50 fee [3021]CHECK EXAMINATION CATEGORYElectrical Contractor [0805] Alarm System Contractor I [0806] Alarm System Contractor II [0807] Residential Electrical Contractor [0808]Utility Line Contractor [0808] Limited Energy Contractor [0808] Sign Specialty Contractor [0808] Lighting Maintenance Contractor [0808]REGISTER COUNTY INFORMATION Please list the county or counties that you are requesting to register. You must submit a current competency card for each county you wish to register.1.6.2.7.3.8.4.9.5.10. 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 INFORMATIONPrimary 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 IIILiability 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 IVQualifier 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. This includes 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:Section V Business to be Qualified Information BUSINESS TO BE QUALIFIEDBusiness Name:Doing Business As (D/B/A):Federal Employer ID Number (FEID):Business Type: ( Sole Proprietor ( LLC ( Corporation (Partnership (Other :_____________ 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.Is this an Additional Business Qualification? ( Yes ( No If Yes, provide the following information:Percentage of ownership you have in the present business you qualify: ______________%Percentage of ownership you have in the business you are attempting to qualify:_______________%BUSINESS CONTACT INFORMATION (IF DIFFERENT THAN APPLICANT INFORMATION)Contact Name:Phone Number of ContactE-Mail Address of ContactBUSINESS LOCATION ADDRESS Street AddressCityStateZip Code (+4 optional)County (if Florida address)CountrySection VI Business Entity Transfer BUSINESS ENTITY TRANSFERThe Business Entity Transfer is required ONLY to transfer a registered license from one business entity to another.Current License Number:Circle One: ER ET EY EZ EI EH EJName of Business No Longer Qualified:Section VII 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 VIII. If YES to questions 2 through 6, please complete Section IX.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.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 VII 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 Sections 2(h and i) of Instructions for detailed instructions on providing complete explanations, including requirements for submitting supporting legal documents. Please complete Section VIII for your response to question 1, and complete Section IX for your response to questions 2 through 6. If you have more than two offenses to document in Section VIII or need additional sheets for Section IX, attach additional pages as necessary. Section VIII 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 IX Explanations for Yes answers to Questions 2-6 Attach additional copies as necessary 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 X Affirmation by Written Declaration AFFIRMATION BY WRITTEN DECLARATION I 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. 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