Form FDACS-10960 "Household Moving Services Registration Application" - Florida

What Is Form FDACS-10960?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FDACS-10960 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-10960 "Household Moving Services Registration Application" - Florida

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Remit Non-Refundable
Florida Department of Agriculture and Consumer Services
Application Fee Online at:
Division of Consumer Services
www.FDACS.gov
- or -
HOUSEHOLD MOVING SERVICES
Check or Money Order payable to
FDACS and remit with application
REGISTRATION APPLICATION
to:
NICOLE “NIKKI” FRIED
FDACS
Chapter 507, Florida Statutes
COMMISSIONER
Rule 5J-15.001, Florida Administrative Code
P.O. Box 6700
Tallahassee, FL 32314-6700
1-800-HELP-FLA (435-7352) • (850) 410-3800
www.FDACS.gov • (850) 410-3804 Fax
All documents and attachments submitted with this application may be subject to public review pursuant to Chapter 119, Florida Statutes
(F.S.). PLEASE TYPE OR PRINT. Additional pages may be attached if extra space is needed. Please ensure that all attachments
reflect the organization’s name or registration number and the number of the corresponding question. Biennial Registration Fee:
$600. Active duty military, honorably discharged veterans, military spouses or surviving spouses may be eligible for a waiver of
the registration fee. See section 507.03, F.S., and rule 5J-15.001, Florida Administrative Code for eligibility requirements.
Business Information
Please Select one:
New Filing
Renewal IM#:
Change of Owner
Previous IM#
Registration Type (Please select):
1 – 2 Vehicles
Intrastate Mover
0 Vehicles
3 or More Vehicles
Moving Broker
1. Business Name
(If applicant is not an individual, state the legal name of the entity as filed with the Florida Department of State, Division of
Corporations):
2. Form of organization:
Corporation
LLC
Partnership
Sole Proprietorship
Other
:
(please describe)
/
/
Date
State:
Charter (Document)#:
Month
Day
Year
legally established:
/
/
If foreign
, date registered with the Florida Department of State:
(out of state corporation/entity)
Month
Day
Year
Fictitious (DBA) Name
:
Date Registered:
(As registered with the Division of Corporations).
/
/
Month
Day
Year
3. Physical Street Address
(Include APT or SUITE # in all address lines.):
City:
State:
Zip Code:
-
Mailing Address
:
(if different from above)
City:
State:
Zip Code:
-
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 001022
$600.00
FDACS-10960 Rev. 04/19
Page 1 of 5
Remit Non-Refundable
Florida Department of Agriculture and Consumer Services
Application Fee Online at:
Division of Consumer Services
www.FDACS.gov
- or -
HOUSEHOLD MOVING SERVICES
Check or Money Order payable to
FDACS and remit with application
REGISTRATION APPLICATION
to:
NICOLE “NIKKI” FRIED
FDACS
Chapter 507, Florida Statutes
COMMISSIONER
Rule 5J-15.001, Florida Administrative Code
P.O. Box 6700
Tallahassee, FL 32314-6700
1-800-HELP-FLA (435-7352) • (850) 410-3800
www.FDACS.gov • (850) 410-3804 Fax
All documents and attachments submitted with this application may be subject to public review pursuant to Chapter 119, Florida Statutes
(F.S.). PLEASE TYPE OR PRINT. Additional pages may be attached if extra space is needed. Please ensure that all attachments
reflect the organization’s name or registration number and the number of the corresponding question. Biennial Registration Fee:
$600. Active duty military, honorably discharged veterans, military spouses or surviving spouses may be eligible for a waiver of
the registration fee. See section 507.03, F.S., and rule 5J-15.001, Florida Administrative Code for eligibility requirements.
Business Information
Please Select one:
New Filing
Renewal IM#:
Change of Owner
Previous IM#
Registration Type (Please select):
1 – 2 Vehicles
Intrastate Mover
0 Vehicles
3 or More Vehicles
Moving Broker
1. Business Name
(If applicant is not an individual, state the legal name of the entity as filed with the Florida Department of State, Division of
Corporations):
2. Form of organization:
Corporation
LLC
Partnership
Sole Proprietorship
Other
:
(please describe)
/
/
Date
State:
Charter (Document)#:
Month
Day
Year
legally established:
/
/
If foreign
, date registered with the Florida Department of State:
(out of state corporation/entity)
Month
Day
Year
Fictitious (DBA) Name
:
Date Registered:
(As registered with the Division of Corporations).
/
/
Month
Day
Year
3. Physical Street Address
(Include APT or SUITE # in all address lines.):
City:
State:
Zip Code:
-
Mailing Address
:
(if different from above)
City:
State:
Zip Code:
-
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 001022
$600.00
FDACS-10960 Rev. 04/19
Page 1 of 5
4. Telephone Number:
Fax Number:
(
)
-
(
)
-
Email Address:
Website:
5. Federal Employer ID Number
:
[s. 119.092, F.S.]
-
List the full names of the Florida registered agent, and all of the owners, officers, directors, managing members,
6.
or general partners (as applicable), as listed with the Florida Department of State, Division of Corporations:
(Attach
additional sheets as necessary using the same format.)
Florida Registered Agent Name
:
(As listed with the Florida Department of State, Division of Corporations.)
Address:
City:
State:
Zip Code:
-
Telephone Number:
Email:
(
)
-
Owners, Officers, Directors, Managing Members or General Partners:
Name:
Title:
Address:
City:
State:
Zip Code:
-
Telephone Number:
Email:
(
)
-
Name:
Title:
Address:
City:
State:
Zip Code:
-
Telephone Number:
Email:
(
)
-
Name:
Title:
Address:
City:
State:
Zip Code:
-
Telephone Number:
Email:
(
)
-
FDACS-10960 Rev. 04/19
Page 2 of 5
7.
List all other business locations or branch offices
:
(Attach additional sheets as necessary using the same format.)
Name:
Telephone Number:
(
)
-
Address:
City:
State:
Zip Code:
-
8.
List all corporations, business entities
and trade names through
(includes LLC, Partnership, Sole Proprietorship, and Other)
which each owner operated, was known, or did business as a mover or moving broker within the last five (5)
years
(State all legal names as filed with the Florida Department of State, Division of Corporations and all fictitious names - attach additional sheets
as necessary using the same format.):
Business Name:
Address:
City:
State:
Zip Code:
-
Telephone Number:
Florida Registration Number:
IM/MB-
(
)
-
9. Have any persons listed in question #6 been convicted of a crime involving fraud, dishonest dealing, or any act
of moral turpitude?
[s. 507.03(8)(b), F.S.]
* If yes, please provide the following information for each individual:
(Attach additional sheets as necessary using the
Yes*
No
same format.)
Name of Individual:
Nature of Offense:
Date:
/
/
Month
Day
Year
Court Having Jurisdiction:
Disposition of Offense:
Date:
/
/
Month
Day
Year
10. Please respond either YES or NO to the questions below for any persons listed in question #6:
Yes*
No
Has any person failed to satisfy a civil fine or penalty arising out of any administrative or enforcement action
brought by any government agency or private person based upon conduct involving fraud, dishonest
dealing, or any violation of Chapter 507, Florida Statutes?
[s. 507.03(8)(c), F.S.]
Yes*
No
Does any person have pending against him or her any criminal, administrative, or enforcement
proceedings in any jurisdiction, based upon conduct involving fraud, dishonest dealing, or any act of moral
turpitude?
[s. 507.03(8)(d), F.S.]
Yes*
No
Has any person had a judgment entered against him or her in any action brought by the department or
the Department of Legal Affairs pursuant to Chapter 507 or ss. 501.201 – 501.213, Florida Statutes?
[s.
507.03(8)(e), F.S.]
* If yes, please provide the following information for each individual:
(Attach additional sheets as necessary using the same format.)
FDACS-10960 Rev. 04/19
Page 3 of 5
Name of Individual:
Agency or Court Issuing the Final Ruling:
Date of Action:
/
/
Month
Day
Year
NOTE: It is a violation of chapter 507, Florida Statutes, for a mover or a moving broker to knowingly refuse or fail to disclose in
writing to a customer before a household move that the mover, or an employee or subcontractor of the mover or moving broker,
who has access to the dwelling or property of the customer, including access to give a quote for the move, has been convicted of
a felony listed in s. 775.21(4)(a)1. or convicted of a similar offense of another jurisdiction, regardless of when such felony offense
was committed.
ATTACH THE FOLLOWING DOCUMENTS AND INITIAL VERIFYING THAT THE INFORMATION PROVIDED IS
COMPLETE:
MOVERS
Certificate of insurance. Coverage must include:
___ Cargo Liability for loss or damage to household goods – not less than $10,000 per shipment
Or if you have two or fewer vehicles you may obtain:
___ Surety Bond
in the amount of $25,000 or an original Certificate of Deposit in the amount of $25,000.
(Original)
AND
___ Motor vehicle coverage, including bodily injury and property damage liability in minimum amounts of:
i. $50,000 per occurrence for a commercial motor vehicle with a gross weight of less than 35,000
pounds.
ii. $100,000 per occurrence for a commercial motor vehicle with a gross weight of more than 35,000
pounds but less than 44,000 pounds.
iii. $300,000 per occurrence for a commercial motor vehicle with a gross weight of 44,000 pounds or
more.
Insurance and surety must be issued by a company authorized to transact business in this state. The department
shall be named as a certificate holder and must be notified at least 10 days before any changes in insurance
coverage. Insurance coverage must be current and maintained throughout the registration period.
BROKERS
___ Surety Bond
in the amount of $25,000 or an original Certificate of Deposit in the amount of $25,000.
(Original)
FDACS-10960 Rev. 04/19
Page 4 of 5
Preparer Information
Prepared By
:
(please print name)
Title of Preparer:
Telephone Number of Preparer:
(
)
-
Application Certification
I am empowered to execute this application on behalf of the above-named entity or individual.
Print Name of Applicant
Title and Phone Number
Signature of Applicant
Date
FDACS-10960 Rev. 04/19
Page 5 of 5
Page of 5