Form DBPR FCL1004 "Addendum to Application for a Farm Labor Contractor Certificate of Registration" - Florida

What Is Form DBPR FCL1004?

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 January 15, 2009;
  • 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 FCL1004 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 FCL1004 "Addendum to Application for a Farm Labor Contractor Certificate of Registration" - Florida

1435 times
Rate (4.7 / 5) 86 votes
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
FARM LABOR REGISTRATION AND TESTING
ADDENDUM TO APPLICATION FOR A FARM LABOR CONTRACTOR
CERTIFICATE OF REGISTRATION
Check only one of the following requests:
____ $125.00 Renewal Application for Registration
____ $160.00 Application for Examination and Registration
____ $ 35.00 Application for Re-Examination Only
Payment must be in the form of a money order/certified check payable to DBPR – Farm Labor
You can apply as an Individual or a Company, but not both:
Individual Name: ___________________________________________ SSN: ___________________
Company Name: ___________________________________________ FEIN: ___________________
Registered Agent Information:
__________________________________________________ __________________
(Name)
(Phone)
_____________________________________________________________________
(Address)
(City)
(State)
(Zip)
I certify that the above referenced individual has been informed and agrees to act as my agent to receive service of
process and other official or legal documents as outlined in 450.31(1)(e), Florida Statutes. I understand that this
agent must be available to accept service during regular business hours, Monday through Friday.
___________________________________
__________________________
(Signature of Applicant)
(Date)
REQUEST FOR EXAMINATION
(CHECK ONLY ONE)
LANGUAGE
WRITTEN
ORAL
ENGLISH
SPANISH
HAITIAN/CREOLE
Please indicate if you require special accommodations due to disability or religion: ____ Yes
____ No
If Yes, please explain: _________________________________________________________________
DBPR FCL 1004 Revised 1/15/2009
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
FARM LABOR REGISTRATION AND TESTING
ADDENDUM TO APPLICATION FOR A FARM LABOR CONTRACTOR
CERTIFICATE OF REGISTRATION
Check only one of the following requests:
____ $125.00 Renewal Application for Registration
____ $160.00 Application for Examination and Registration
____ $ 35.00 Application for Re-Examination Only
Payment must be in the form of a money order/certified check payable to DBPR – Farm Labor
You can apply as an Individual or a Company, but not both:
Individual Name: ___________________________________________ SSN: ___________________
Company Name: ___________________________________________ FEIN: ___________________
Registered Agent Information:
__________________________________________________ __________________
(Name)
(Phone)
_____________________________________________________________________
(Address)
(City)
(State)
(Zip)
I certify that the above referenced individual has been informed and agrees to act as my agent to receive service of
process and other official or legal documents as outlined in 450.31(1)(e), Florida Statutes. I understand that this
agent must be available to accept service during regular business hours, Monday through Friday.
___________________________________
__________________________
(Signature of Applicant)
(Date)
REQUEST FOR EXAMINATION
(CHECK ONLY ONE)
LANGUAGE
WRITTEN
ORAL
ENGLISH
SPANISH
HAITIAN/CREOLE
Please indicate if you require special accommodations due to disability or religion: ____ Yes
____ No
If Yes, please explain: _________________________________________________________________
DBPR FCL 1004 Revised 1/15/2009