Florida Department of Agriculture and Consumer Services
Division of Licensing
APPLICATION FOR
SECURITY OFFICER LICENSE
Chapter 493, Florida Statutes
Rule 5N-1.100, Florida Administrative Code
www.mylicensesite.com
S M I T H 1 2 3
BEFORE YOU BEGIN, read the Application Instructions. TYPE or PRINT using black ink. To help avoid unnecessary
delay in the processing of your application, be sure to answer all questions and submit any necessary documentation.
SECTION I APPLICANT INFORMATION
If you are not a United States citizen,
you must also provide your 8- or
9- digit Alien Registration Number.
SOCIAL SECURITY NUMBER ALIEN REGISTRATION NUMBER
SEE APPLICATION INSTRUCTIONS A
NICOLE “NIKKI” FRIED
COMMISSIONER
SEX RACE EYE COLOR HAIR COLOR DATE OF BIRTH (MMDDYYYY) WEIGHT HEIGHT
D P D F 0 1
Page 1 of 5
FOR DIVISION OF LICENSING USE ONLY TYPE OR PRINT USING BLACK INK
PLACE LETTER/NUMBER INSIDE EACH BOX AS SHOWN.
LAST NAME FIRST NAME MI
CITY STATE ZIP CODE +4
-
RESIDENCE ADDRESS
RESIDENCE ADDRESS CONTINUED (SUITE, BUILDING, APT., ETC)
CITY STATE ZIP CODE +4
-
MAILING ADDRESS IF DIFFERENT FROM ABOVE
MAILING ADDRESS CONTINUED (SUITE, BUILDING, APT., ETC)
PLACE OF BIRTH (Include STATE OR PROVINCE --- AND COUNTRY)
HOME PHONE NUMBER (Numbers only; no dashes or parentheses.) WORK PHONE NUMBER (Numbers only; no dashes or parentheses.)
E-MAIL ADDRESS
LBS FT IN
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