Form DH4116 "Application for Septic Tank Contracting Course Provider" - Florida

Form DH4116 or the "Application For Septic Tank Contracting Course Provider" is a form issued by the Florida Department of Health.

The form was last revised in July 1, 2003 and is available for digital filing. Download an up-to-date Form DH4116 in PDF-format down below or look it up on the Florida Department of Health Forms website.

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Download Form DH4116 "Application for Septic Tank Contracting Course Provider" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTING
COURSE PROVIDER
COURSE PROVIDER APPLICATION FEE $250.00. FORWARD COMPLETED APPLICATION TO:
DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
SECTION I
PROVIDER NAME
MAILING ADDRESS
TELEPHONE NUMBER
FACSIMILE NUMBER
SECTION II
PLEASE INDICATE THE STRUCTURE OF YOUR BUSINESS BY CHECKING ONE OF THE FOLLOWING:
SOLE
CORPORATION
PARTNERSHIP
MEMBERSHIP
PROPRIETORSHIP
REGISTERED AGENT & OFFICERS  PARTNERS
MEMBERSHIP DIRECTORS  OWNER NAME
ADDRESS
POSITION
SECTION III
I AFFIRM THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT.
Print or Type Name of Authorized Representative
Signature of Authorized Representative
Date
FOR
Check Number
Approval Date
HSES
Check Date
Expiration Date
OFFICE
Check Amount
Provider #
USE
Denial Date
Reviewed By
ONLY
DH 4116, 07/03 Incorporated: Policy on Requirements for Continuing Education Courses and Course Providers
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTING
COURSE PROVIDER
COURSE PROVIDER APPLICATION FEE $250.00. FORWARD COMPLETED APPLICATION TO:
DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
SECTION I
PROVIDER NAME
MAILING ADDRESS
TELEPHONE NUMBER
FACSIMILE NUMBER
SECTION II
PLEASE INDICATE THE STRUCTURE OF YOUR BUSINESS BY CHECKING ONE OF THE FOLLOWING:
SOLE
CORPORATION
PARTNERSHIP
MEMBERSHIP
PROPRIETORSHIP
REGISTERED AGENT & OFFICERS  PARTNERS
MEMBERSHIP DIRECTORS  OWNER NAME
ADDRESS
POSITION
SECTION III
I AFFIRM THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT.
Print or Type Name of Authorized Representative
Signature of Authorized Representative
Date
FOR
Check Number
Approval Date
HSES
Check Date
Expiration Date
OFFICE
Check Amount
Provider #
USE
Denial Date
Reviewed By
ONLY
DH 4116, 07/03 Incorporated: Policy on Requirements for Continuing Education Courses and Course Providers
INSTRUCTIONS:
SECTION I
Provider name:
Name of the organization or sponsor seeking approval to provide septic tank
contracting continuing education courses.
Mailing address:
Mailing address of the organization or sponsor seeking course provider
approval.
Telephone #:
Telephone number of the organization or sponsor seeking course provider
approval.
Facsimile #:
Facsimile number of the organization or sponsor seeking course provider
approval.
SECTION II
Mark the box under the business type that describes the business structure of the organization or
sponsor seeking course provider approval.
List the name, address and position of the registered agent and officers, all partners,
membership directors, or owners of the organization or sponsor seeking course provider
approval.
SECTION III
The authorized representative of the organization or sponsor seeking course provider approval
acknowledges understanding of the affirmation statement by printing, signing and dating the
application.
Mail completed application to :
DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
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