Form DBPR ALU5 "Application for Financially Responsible Officer" - Florida

What Is Form DBPR ALU5?

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 October 1, 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 ALU5 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DBPR ALU5 "Application for Financially Responsible Officer" - Florida

Download PDF

Fill PDF online

Rate (4.4 / 5) 60 votes
1 of 9
State of Florida
Department of Business and Professional Regulation
Asbestos Licensing Unit
Application for Financially Responsible Officer
Form # DBPR ALU 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Remove Financially
Complete Sections II and VII of this application.
Responsible Officer
Complete Sections III-VII application.
Fee of $100 for Financially Responsible Officer application
Credit report on applicant from a nationally recognized credit reporting
Add Financially
agency, which includes a public records statement that records have been
Responsible Officer
checked at local, state, and federal levels.
Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if
applicable.
Supporting legal documentation, if necessary.
Complete this entire application.
Fee of $100 for Financially Responsible Officer application
Credit report on applicant from a nationally recognized credit reporting
agency, which includes a public records statement that records have been
Change Financially
checked at local, state, and federal levels.
Responsible Officer
Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if
applicable.
Supporting legal documentation, if necessary.
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. General Requirements for Financially Responsible Officer
a. Definition of “Financially Responsible Officer”-
i.
A person other than the primary qualifying agent who with the approval of the board
assumes personal responsibility for all financial aspects of the business organization.
ii.
The Financially Responsible Officer has final approval authority on all business matters,
including contracts, specifications, checks, drafts, or payments, regardless of the form of
payment, made by the business entity.
2. Application Instructions (by section)
a. Section I- Application Type
i.
Remove Financially Responsible Officer
(1)
Select this application type if the qualified business decides to remove the Financially
Responsible Officer and assign responsibility for all financial aspects of the business
organization to the primary qualifying agent.
(2)
Complete Sections II and VIII.
ii.
Add Financially Responsible Officer
(1)
Select this application type if the qualified business with a primary qualifier decides to
appoint a Financially Responsible Officer to have responsibility for all financial
aspects of the business organization.
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003
1 of 9
State of Florida
Department of Business and Professional Regulation
Asbestos Licensing Unit
Application for Financially Responsible Officer
Form # DBPR ALU 5
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Remove Financially
Complete Sections II and VII of this application.
Responsible Officer
Complete Sections III-VII application.
Fee of $100 for Financially Responsible Officer application
Credit report on applicant from a nationally recognized credit reporting
Add Financially
agency, which includes a public records statement that records have been
Responsible Officer
checked at local, state, and federal levels.
Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if
applicable.
Supporting legal documentation, if necessary.
Complete this entire application.
Fee of $100 for Financially Responsible Officer application
Credit report on applicant from a nationally recognized credit reporting
agency, which includes a public records statement that records have been
Change Financially
checked at local, state, and federal levels.
Responsible Officer
Proof of satisfaction of liens, judgments, and discharge of bankruptcy, if
applicable.
Supporting legal documentation, if necessary.
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. General Requirements for Financially Responsible Officer
a. Definition of “Financially Responsible Officer”-
i.
A person other than the primary qualifying agent who with the approval of the board
assumes personal responsibility for all financial aspects of the business organization.
ii.
The Financially Responsible Officer has final approval authority on all business matters,
including contracts, specifications, checks, drafts, or payments, regardless of the form of
payment, made by the business entity.
2. Application Instructions (by section)
a. Section I- Application Type
i.
Remove Financially Responsible Officer
(1)
Select this application type if the qualified business decides to remove the Financially
Responsible Officer and assign responsibility for all financial aspects of the business
organization to the primary qualifying agent.
(2)
Complete Sections II and VIII.
ii.
Add Financially Responsible Officer
(1)
Select this application type if the qualified business with a primary qualifier decides to
appoint a Financially Responsible Officer to have responsibility for all financial
aspects of the business organization.
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003
2 of 9
(2)
Complete Sections III-VIII.
iii.
Change Financially Responsible Officer
(1)
Select this application type if the qualified business with a current Financially
Responsible Officer decides to change the person who is appointed as the
Financially Responsible Officer.
(2)
Complete this entire application.
b. Section II- Remove Financially Responsible Officer (Complete only if you will be removing
or changing a Financially Responsible Officer.)
i.
Complete this section entirely.
ii.
Provide the name of the Financially Responsible Officer to be removed.
iii.
Provide the name of the business from which the Financially Responsible Officer will be
removed. Provide the name of the business as it is registered with the Florida Division of
Corporations. Provide the business license number.
iv.
Provide the name of the Primary Qualifier of the business from which the Financially
Responsible Officer will be removed.
v.
Provide the license number of the Primary Qualifier named above.
c. Section III- Financially Responsible Personal Information
i.
Fill out each section completely.
ii.
Provide the name of the business for which you are applying to be a Financially
Responsible Officer. Provide the name of the business as it is registered with the Florida
Division of Corporations. Provide the business license number.
iii.
Provide the name and license number for the Primary Qualifier of the business for which
you are applying to be a Financially Responsible Officer.
iv.
Applicant to be a Financially Responsible Officer must provide their Social Security
number. A Social Security number is required in order to apply for any individual license
within the Department of Business and Professional Regulation.
v.
In the Full Legal Name section provide your full legal name as it appears on your Social
Security card. Do not use any nicknames or initials. Please list any aliases or prior names
in the prior name information section.
vi.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
vii.
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.
viii.
Applicants are required to provide at least one physical address – i.e., not a P.O. Box. If
the mailing address is not also your physical address, please provide a physical address.
ix.
Applicants must provide the address for the business for which they are applying to be a
Financially Responsible Officer.
x.
Additional contact information is optional and will be used when the applicant cannot be
reached using their primary contact information.
xi.
Applicants must provide information on any prior names or aliases used by applicant. If
the name on supporting documentation does not match the applicant’s legal name, the
alias used in the supporting documentation must be provided in this section. Failure to do
so will result in a deficient application.
d. Section IV- Background Questions
i.
Applicants must submit answers to each of the background questions.
ii.
For each “Yes” answer the person must provide an explanation in Section V or VI, as
applicable.
e. Section V- Explanations for Background Questions 1 and 2
i.
For this section, provide as much detail as possible.
ii.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section V [make additional
copies as necessary] of the application please provide the full details of the criminal
charges including dates, outcomes, sentences, and/or conditions imposed; the dates,
name and location of the court and/or jurisdiction in which any proceedings were held
or are pending. If you answer NO to this question because you believe that previous
incidents have been dismissed, no action taken, nolle prossed, or expunged, you
may be asked to supply documentation as proof of the disposition.
iii.
Question 2:
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003
3 of 9
(1)
If you answer “yes” to this question, you must complete Section V [make additional
copies as necessary] of the application and you must also supply documentation
proving the bankruptcy has been discharged or the judgment or lien has been
satisfied, or if not, stating the current status of the bankruptcy, judgment or lien.
iv.
Submit supporting legal documentation, if necessary, with this application.
f.
Section VI- Explanations for Background Questions 3 and 4
i.
For this section, provide as much detail as possible.
ii.
Question 3:
(1)
If you answer “yes” to this question, you must complete Section VI [make additional
copies as necessary] of the application and supply copies of documentation
explaining the denial or pending action.
(2)
Provide the full details explaining the denial or pending administrative action
including the nature of any charges, dates, outcomes, sentences, and/or conditions
imposed; the dates, name and location of the court and/or jurisdiction in which any
proceedings were held or are pending; and the designation and/or license number for
any actions against a license or licensure application.
iii.
Question 4:
(1)
If you answer “yes” to this question, you must complete Section VI [make additional
copies as necessary] of the application and supply copies of the order(s) (if
applicable) showing the disciplinary action taken against the license or
documentation showing the status of the pending action.
(2)
Provide the full details of any administrative action including the nature of any
charges, dates, outcomes, sentences, and/or conditions imposed; the dates, name
and location of the court and/or jurisdiction in which any proceedings were held or are
pending; and the designation and/or license number for any actions against a license
or licensure application.
iv.
Submit supporting legal documentation, if necessary, with this application.
g. Section VII- Affirmation by Written Declaration
h.
The Financially Responsible Officer must sign the affirmation by written declaration.
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003
4 of 9
State of Florida
Department of Business and Professional Regulation
Asbestos Licensing Unit
Application for Financially Responsible Officer
Form # DBPR ALU 5
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 end of this application.
Section I – Application Type
CHECK ONE OF THE APPLICATION TYPES
Remove Financially Responsible Officer (Complete Sections II and VIII) [5903/9006]
Add Financially Responsible Officer (Complete Sections III-VIII.) [5903/3022]
Change Financially Responsible Officer (Complete this entire application) [5903/3022]
Section II – Remove Financially Responsible Officer
NOTE: If the business entity does not appoint a new Financially Responsible Officer, ALL Primary
Qualifying Agents will be jointly and severally liable for all construction and business matters of
the business entity.
BUSINESS INFORMATION
Name of Financially Responsible Officer to be removed:
Name of Business:
License Number of Business:
Name of Primary Qualifier:
License Number of Primary Qualifier:
Section III – Financially Responsible Officer Personal Information
BUSINESS INFORMATION
Name of business for which you are applying to be Financially Responsible Officer:
License Number of Business:
Name of Primary Qualifier of Business for which you are applying to be Financially Responsible Officer:
License Number of Primary Qualifier of Business for which you are applying to be Financially Responsible
Officer:
Financially Responsible Officer to be Appointed
Social Security Number*
FULL LEGAL NAME
Last Name
First
Middle
Title
Suffix
Birth Date (MM/DD/YYYY)
Gender
/
/
 Male  Female
* 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.
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003
5 of 9
Section III – Financially Responsible Officer Personal Information - continued
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
BUSINESS LOCATION ADDRESS
Business/Firm Name
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
PRIOR NAME INFORMATION
Have you used, been known as, or are currently known by another name ((example - maiden name,
pseudonym, nickname) or alias other than the name signed to the application? 
Yes
No
If your answer is yes, state name or names used below:
Last Name
First
Middle
Title
Suffix
Last Name
First
Middle
Title
Suffix
Last Name
First
Middle
Title
Suffix
DBPR ALU 5 Financially Responsible Officer
2012 October
Incorporated by Rule: 61-35.003