Form FDACS-03579 "Lp Gas Category Ii Dispenser License Application" - Florida

What Is Form FDACS-03579?

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 May 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-03579 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-03579 "Lp Gas Category Ii Dispenser License Application" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit with
form to:
LP GAS CATEGORY II
DISPENSER LICENSE APPLICATION
FDACS
P.O. Box 6700
Chapter 527, Florida Statutes
NICOLE “NIKKI” FRIED
Tallahassee, Florida 32314-6700
Rule 5J-20.004, Florida Administrative Code
COMMISSIONER
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license application
fee, to the Bureau of Compliance [(850) 921-1600] at the address in the upper right-hand corner.
Business Name or DBA
Company Name or Corporation:
:
(Name to be printed on license)
Physical Address
Company Mailing Address:
:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Gas Supplier License #:
Supplier Company Name and Address:
Name:
Gas Supplier Phone #:
Address:
Gas Supplier Email Address:
Authorized Gas Supplier Representative:
Name:
Authorized Gas Supplier Representative Signature
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE. Pursuant to Section
527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage liability covering the products and
operations of the business is required. A $1,000,000 surety bond may be submitted in lieu of the required proof of insurance.
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03579 05/19
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit with
form to:
LP GAS CATEGORY II
DISPENSER LICENSE APPLICATION
FDACS
P.O. Box 6700
Chapter 527, Florida Statutes
NICOLE “NIKKI” FRIED
Tallahassee, Florida 32314-6700
Rule 5J-20.004, Florida Administrative Code
COMMISSIONER
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license application
fee, to the Bureau of Compliance [(850) 921-1600] at the address in the upper right-hand corner.
Business Name or DBA
Company Name or Corporation:
:
(Name to be printed on license)
Physical Address
Company Mailing Address:
:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Gas Supplier License #:
Supplier Company Name and Address:
Name:
Gas Supplier Phone #:
Address:
Gas Supplier Email Address:
Authorized Gas Supplier Representative:
Name:
Authorized Gas Supplier Representative Signature
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE. Pursuant to Section
527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage liability covering the products and
operations of the business is required. A $1,000,000 surety bond may be submitted in lieu of the required proof of insurance.
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03579 05/19
Page 1 of 2
QUALIFIERS: List the names and certificate numbers of all qualifiers employed by this company below. Attach a
separate sheet if necessary. A separate qualifier is required for every 10 employees.
Indicate number of employees at this location____________
NAME
CERTIFICATE NUMBER
1.
2.
3.
4.
Has the owner/applicant been convicted or pled nolo contendere to a felony as defined in Rule 5J-20.005, F.A.C.,
within the last five years? If yes, please explain.
NO
YES _____________________________________________________________
PRINT NAME OF OWNER/APPLICANT:
SIGNATURE OF OWNER/APPLICANT:
NAME OF PERSON PREPARING APPLICATION:
PREPARER’S PHONE NO:
PREPARER’S EMAIL ADDRESS:
PREPARER’S TITLE OR OFFICE HELD:
DATE OF APPLICATION:
FDACS-03579 05/19
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