Form FDACS-03584 "Lp Gas Qualifier and Master Qualifier Registration Application" - Florida

Form FDACS-03584 or the "Lp Gas Qualifier And Master Qualifier Registration Application" is a form issued by the Florida Department of Agriculture and Consumer Services.

The form was last revised in August 1, 2018 and is available for digital filing. Download an up-to-date fillable Form FDACS-03584 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-03584 "Lp Gas Qualifier and Master Qualifier Registration Application" - Florida

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Florida Department of Agriculture and Consumer Services
Remit Payment Online at:
Division of Consumer Services
www.fl-ag-online.com
Check or Money Order payable
LP GAS QUALIFIER AND MASTER
to FDACS and remit with form to:
QUALIFIER REGISTRATION APPLICATION
ADAM H. PUTNAM
FDACS
COMMISSIONER
Post Office Box 6700
Sections 527.02 and 527.0201, Florida Statutes
Tallahassee, Florida 32314-6700
To schedule an examination, complete this form (print or type) and return to the above address with the examination
fee or schedule online at www.fl-ag-online.com. QUESTIONS SHOULD BE DIRECTED TO: LP Gas Program (850)
921-1600. If renewing your qualifier/master qualifier online go to freshfromflorida.com. Please attach proof of
approved 16 CEU hours. Questions, please contact Bureau of Compliance (850) 921-1600.
Name: First
Middle:
Last:
Mailing Address:
Applicant Email Address:
City:
State:
Zip:
Phone No:
Company Email Address:
(
)
Company’s LP Gas License #:
Company Name:
Company Phone:
Company Address:
(
)
Check
Exam Type / Qualifier Renewal
Fee
One
Q1: Dealer Exam
$20
Q2: Dispenser Exam
$20
Q5
Service/Installation Exam
$20
:
M1: Master Qualifier Exam: Dealer
Qualifier ID #______________
$30
M5: Master Qualifier Exam: Installer
Qualifier ID#_______________
$30
$30 / $20
Master Qualifier Renewal ID# __________
Qualifier Renewal ID# ___________
Please Choose an Examination Site:
Tallahassee
Tampa
Pompano Beach
Ocala (May only)
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 001171
$20/$30
FDACS-03584 08/18
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Remit Payment Online at:
Division of Consumer Services
www.fl-ag-online.com
Check or Money Order payable
LP GAS QUALIFIER AND MASTER
to FDACS and remit with form to:
QUALIFIER REGISTRATION APPLICATION
ADAM H. PUTNAM
FDACS
COMMISSIONER
Post Office Box 6700
Sections 527.02 and 527.0201, Florida Statutes
Tallahassee, Florida 32314-6700
To schedule an examination, complete this form (print or type) and return to the above address with the examination
fee or schedule online at www.fl-ag-online.com. QUESTIONS SHOULD BE DIRECTED TO: LP Gas Program (850)
921-1600. If renewing your qualifier/master qualifier online go to freshfromflorida.com. Please attach proof of
approved 16 CEU hours. Questions, please contact Bureau of Compliance (850) 921-1600.
Name: First
Middle:
Last:
Mailing Address:
Applicant Email Address:
City:
State:
Zip:
Phone No:
Company Email Address:
(
)
Company’s LP Gas License #:
Company Name:
Company Phone:
Company Address:
(
)
Check
Exam Type / Qualifier Renewal
Fee
One
Q1: Dealer Exam
$20
Q2: Dispenser Exam
$20
Q5
Service/Installation Exam
$20
:
M1: Master Qualifier Exam: Dealer
Qualifier ID #______________
$30
M5: Master Qualifier Exam: Installer
Qualifier ID#_______________
$30
$30 / $20
Master Qualifier Renewal ID# __________
Qualifier Renewal ID# ___________
Please Choose an Examination Site:
Tallahassee
Tampa
Pompano Beach
Ocala (May only)
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 001171
$20/$30
FDACS-03584 08/18
Page 1 of 2
MASTER QUALIFIER FOR A LICENSED COMPANY (Complete this section if you are applying for the Master Qualifier
position for a licensed company).
This form is submitted as evidence that I am eligible to hold the position of Master Qualifier with the company listed on
page 1 of this application, and that I am the (check one) ____owner,____manager,____ supervisor,____ otherwise
primarily responsible party for the operations and business activities of the licensed location or licensed applicant listed
above.
_____________________________________________________
_________________________________________
Signature of Applicant
Date
First time Master Qualifier applicants must have been a registered qualifier for a minimum of three years preceding
submission of this application.
Has the 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 _____________________________________________________________
Signature of Applicant: _____________________________________________________________
DOCUMENTATION OF CONTINUING EDUCATION FOR RENEWAL OF QUALIFIER/MASTER QUALIFIER
(Attach additional sheets as necessary using the same format below to complete the following CEU training information.)
Date of Training
Total
Course ID (if
COURSE TITLE
Hours
applicable)
FDACS-03584 08/18
Page 2 of 2
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