Form DBPR AA-4103 "Change of Status Application" - Florida

What Is Form DBPR AA-4103?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - 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 29, 2012;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • 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 DBPR AA-4103 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR AA-4103 "Change of Status Application" - Florida

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State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Change of Status Application
Form # DBPR AA-4103
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Fee of $290. Make check payable to the Florida Department of Business
Set to Active
and Professional Regulation.
(reactivation outside
 Completed form DBPR AA-4103 – Change of Status Application.
renewal cycle)
 Fee of $25. Make check payable to the Florida Department of Business
Set to Inactive
and Professional Regulation.
(deactivation outside
 Completed form DBPR AA-4103 – Change of Status Application.
renewal cycle)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by Section)
a. Section I- Application Type
i.
Set to Active: This transaction is used to request that the license be reactivated outside
the renewal cycle. The license has already been renewed in an “inactive” status but now
the licensee wishes to place their license in an “active” status.
ii.
Set to Inactive: This transaction is used to request that the license be deactivated
outside the renewal cycle. If the license was in an “inactive” status prior to renewing and
the licensee renewed in an “active” status, the licensee is not allowed to request that their
license be returned to an “inactive” status again. The licensee must then wait until the
next renewal cycle to request the “inactive” status.
b. Section II- Applicant Information
i.
Fill out each section completely.
ii.
In the Full Legal Name section provide your full legal name as it appears on your license.
Do not use any nicknames or initials. Please list any aliases or prior names in the prior
name information section.
iii.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
iv.
Contact information is often used to quickly resolve questions with applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
c. Section III- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR AA 4103- Change of Status Application
Incorporated by Rule: 61-35.004
May 29, 2012
1 of 2
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Change of Status Application
Form # DBPR AA-4103
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Fee of $290. Make check payable to the Florida Department of Business
Set to Active
and Professional Regulation.
(reactivation outside
 Completed form DBPR AA-4103 – Change of Status Application.
renewal cycle)
 Fee of $25. Make check payable to the Florida Department of Business
Set to Inactive
and Professional Regulation.
(deactivation outside
 Completed form DBPR AA-4103 – Change of Status Application.
renewal cycle)
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, Fl 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by Section)
a. Section I- Application Type
i.
Set to Active: This transaction is used to request that the license be reactivated outside
the renewal cycle. The license has already been renewed in an “inactive” status but now
the licensee wishes to place their license in an “active” status.
ii.
Set to Inactive: This transaction is used to request that the license be deactivated
outside the renewal cycle. If the license was in an “inactive” status prior to renewing and
the licensee renewed in an “active” status, the licensee is not allowed to request that their
license be returned to an “inactive” status again. The licensee must then wait until the
next renewal cycle to request the “inactive” status.
b. Section II- Applicant Information
i.
Fill out each section completely.
ii.
In the Full Legal Name section provide your full legal name as it appears on your license.
Do not use any nicknames or initials. Please list any aliases or prior names in the prior
name information section.
iii.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
iv.
Contact information is often used to quickly resolve questions with applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
c. Section III- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR AA 4103- Change of Status Application
Incorporated by Rule: 61-35.004
May 29, 2012
2 of 2
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Change of Status Application
Form # DBPR AA-4103
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
APPLICATION TYPES (Check only one.)
Set to Active [6001/3020]
Set to Inactive [6001/4020]
Section II – Licensee Information
LICENSEE INFORMATION
Last/Surname
First
Middle
Suffix
License Number
Phone Number
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
E-Mail Address
Please be advised that an inactive license will prohibit you from acting as a licensed Athlete Agent under
any and all circumstances in this state. If you wish to return to active status, you must request
reactivation, pay all applicable reactivation and renewal fees, and comply with all applicable license
renewal requirements. Any Athlete Agent working on an inactive license is subject to disciplinary action.
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
Section III – Affirmation By Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR AA 4103- Change of Status Application
Incorporated by Rule: 61-35.004
May 29, 2012
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