SECTION IX PERSONAL INQUIRY WAIVER AND NOTARIZATION STATEMENT
THIS APPLICATION IS EXECUTED UNDER OATH. FALSIFICATION OR MISREPRESENTATION OF ANY PART OR ANY
DOCUMENT SUBJECTS THE APPLICANT TO CRIMINAL PROSECUTION UNDER SECTION 837.06, FLORIDA STATUTES
Do not sign the application until you are in the presence of the Notary Public who will notarize your application.
I certify that I understand that the Division of Licensing will conduct any investigation deemed necessary
to ensure that I have met all statutory requirements for licensure. I understand that inquiry shall be made
regarding my criminal history and that subsequent investigation may include my school records, employment
history, nancial records, any history of controlled substance or alcohol abuse, and my mental capacity.
I hereby waive any provision of law forbidding any school ofcial, court, police agency, employer, rm or
person from disclosing to the Division any knowledge or information concerning me, and I do certify that I give
permission for such entity to disclose any information and to provide any record requested concerning me to
the Division.
I also afrm that the information contained in this application and all attachments I have submitted to be true
and correct to the best of my knowledge. I understand that falsication of any information or documentation
submitted with this application may be grounds for denial or revocation of the license.
Signature of Applicant Date Signed
STATE OF FLORIDA
COUNTY OF
day of , 20 by:
PRINT Name of Applicant NOTARY SIGNATURE
PRINT, TYPE, OR STAMP NAME OF NOTARY
Personally Known Produced Identication
FDACS-16007 Rev. 01/17
Page 5 of 5
SECTION X EMPLOYER STATEMENT (TO BE COMPLETED BY APPLICANT’S EMPLOYER)
Agency Name:
Agency License #:
Name of Agency Head or Designee (type or print):
Signature:
Agency Phone #: Date Signed: