SECTION V PERSONAL HISTORY
c. Have you ever been diagnosed with a mental illness?
d Do you currently abuse any controlled substance?
e. Do you have a history of controlled substance abuse?
abuse rehabilitation program and three letters of reference, one of which should be from
f. Do you have a history of alcohol abuse?
a.
Section VI of the APPLICATION INSTRUCTIONS.
original
b.
licensed:
STATE:______________ PERIOD OF LICENSURE:________________________
STATE:______________ PERIOD OF LICENSURE:________________________
c.
proceeding in Florida or another state?
If YES, provide on a separate sheet of paper complete details regarding this action,
SECTION VII CERTIFICATION OF QUALIFIED EXEMPTION FROM PUBLIC RECORD DISCLOSURE
record disclosure. Leave blank if not applicable.
SECTION VIII CITIZENSHIP
a. Have you ever renounced (relinquished) U.S. citizenship?
b. Are you a citizen of the United States? If YES, proceed to Section IX.
must
c. Are you deemed a lawful permanent resident alien by the United States Citizenship and
Immigration Services (USCIS)?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO