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SECTION V PERSONAL HISTORY
a. If you have ever been adjudicated incapacitated (determined by the court to be incapable of taking care of yourself),
you must provide a copy of the court document restoring your capacity.
b. If you have ever been involuntarily placed in a treatment facility for the mentally ill under Chapter 394, F. S., or
similar laws of another state, you must provide a copy of the court document restoring your competency.
c. If you have ever been diagnosed with a mental illness, you must provide a statement from a psychologist or
psychiatrist licensed in Florida attesting that you are not currently suffering from a mental illness that precludes you
d. If you are currently abusing a controlled substance, you are not eligible for licensure.
e. If you have a history of controlled substance abuse, you must provide evidence of successful completion of a
substance abuse rehabilitation program and three letters of reference, one of which should be from your sponsor
in the program.
f. If you have a history of alcohol abuse, you must provide evidence of successful completion of an alcohol rehabilitation
program and three letters of reference, one of which should be from your sponsor in the program.
SECTION VI TRAINING/EXPERIENCE
You must submit proof of successful completion of a minimum of 40 hours of professional training provided by a
Exceptions:
1.
2.
3.
4. Relevant military training or education received and completed during service in the United States Armed Forces.
SECTION VII CERTIFICATION OF QUALIFIED EXEMPTION FROM PUBLIC RECORDS DISCLOSURE
Section 119.071, F.S.,
numbers, Social Security numbers, and photographs pertaining to certain individuals. To determine whether you
qualify for an exemption, read the complete text of the law on line at IF YOU
QUALIFY FOR EXEMPTION, answer this question to specify whether you want the statutorily exempt information to
be kept from public disclosure. If you do NOT qualify for the exemption, leave it blank.
SECTION VIII CITIZENSHIP
If you are not a U.S. Citizen, you must submit proof of current employment authorization issued by the Department of
Homeland Security, U.S. Citizenship and Immigration Services (USCIS). A COPY of the front and back of one of the
Do not sign the application until you are in the presence of the Notary Public who will notarize your application.