Form DBPR PG4705 "Application for License From Null and Void (Expired License)" - Florida

What Is Form DBPR PG4705?

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 June 1, 2016;
  • 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 printable version of Form DBPR PG4705 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 PG4705 "Application for License From Null and Void (Expired License)" - Florida

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State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for License from Null and Void (Expired License)
Form # DBPR PG 4705
APPLICATION CHECKLIST — IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Pay $475.00 fee. (Make check payable to the Department of
Licensure from Null and
Business and Professional Regulation.)
Void
Supporting legal documentation (if applicable). See Section 2(c) of
Instructions
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 form, please contact the Department of
Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Application for Licensure Through Null and Void Transaction
a. All portions of the application must be completed.
b. This application should only be used by persons who have previously held a license
as a Professional Geologist.
c. If your name has changed since your original license went null and void, you must submit
documentation supporting this change. Acceptable documentation includes copies of legally
recorded marriage certificates, divorce decrees, or other court documents. We suggest you
submit copies of original documents as we will not return this documentation to you.
d. Fee: $475.00. (make check payable to the Department of Business and Professional
Regulation.)
2. Application Instructions
a. Section I
i.
Check only one of the application types.
ii.
Provide your previous license number.
b. Section II
i.
Fill out each section completely.
ii.
In the Full Legal Name section, applicants must use the name as it appears on his or her
Social Security card. Do not use nicknames or initials.
iii.
Applicants must furnish their current mailing address.
iv.
Applicant’s addresses are used only for Department purposes and will not be printed on
the license.
v.
List all states or countries where you have held a license to practice barbering.
vi.
List the date each license was acquired.
vii.
All names, prior or current, other than the name signed to the application must be listed.
c. Section III (a), (b), and (c)
i.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the arrest
report, copies of the disposition or final order(s), and documentation proving all
sanctions have been served and satisfied. You must supply this documentation
for each occurrence. If you are unable to supply this documentation, a certified
statement from the clerk of court for the relevant jurisdiction stating the status of
records is required.
DBPR PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for License from Null and Void (Expired License)
Form # DBPR PG 4705
APPLICATION CHECKLIST — IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Complete all sections of this application.
Pay $475.00 fee. (Make check payable to the Department of
Licensure from Null and
Business and Professional Regulation.)
Void
Supporting legal documentation (if applicable). See Section 2(c) of
Instructions
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 form, please contact the Department of
Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Application for Licensure Through Null and Void Transaction
a. All portions of the application must be completed.
b. This application should only be used by persons who have previously held a license
as a Professional Geologist.
c. If your name has changed since your original license went null and void, you must submit
documentation supporting this change. Acceptable documentation includes copies of legally
recorded marriage certificates, divorce decrees, or other court documents. We suggest you
submit copies of original documents as we will not return this documentation to you.
d. Fee: $475.00. (make check payable to the Department of Business and Professional
Regulation.)
2. Application Instructions
a. Section I
i.
Check only one of the application types.
ii.
Provide your previous license number.
b. Section II
i.
Fill out each section completely.
ii.
In the Full Legal Name section, applicants must use the name as it appears on his or her
Social Security card. Do not use nicknames or initials.
iii.
Applicants must furnish their current mailing address.
iv.
Applicant’s addresses are used only for Department purposes and will not be printed on
the license.
v.
List all states or countries where you have held a license to practice barbering.
vi.
List the date each license was acquired.
vii.
All names, prior or current, other than the name signed to the application must be listed.
c. Section III (a), (b), and (c)
i.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the arrest
report, copies of the disposition or final order(s), and documentation proving all
sanctions have been served and satisfied. You must supply this documentation
for each occurrence. If you are unable to supply this documentation, a certified
statement from the clerk of court for the relevant jurisdiction stating the status of
records is required.
DBPR PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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(2)
If you are still on probation, you must supply a letter from your probation officer, on
official letterhead, stating the status of your probation.
ii.
Question 2:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the judgment
or decree. You must also supply documentation proving all sanctions have been
served and satisfied, or if not, stating the current status of any proceedings.
iii.
Question 3:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of
documentation explaining the denial or pending action.
iv.
Question 4:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of the order(s)
showing the disciplinary action taken against the license, or documentation showing
the status of the pending action.
d. Section IV
i.
Provide an explanation of the illness or economic hardship that prevented renewal of
your license.
ii.
Attach additional copies as necessary
e. Section IV
i.
Please read and sign the affirmation by written declaration. If the applicant fails to sign
the affirmation statement, the Department will not process the application.
DBPR PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for License from Null and Void (Expired License)
Form # DBPR PG 4705
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
CHECK ONLY ONE OF THE APPLICATION TYPES
 Geologist License from Null and Void [5301/1038]
PREVIOUS LICENSE INFORMATION
Previous License Number
Section II – Applicant Information
APPLICANT INFORMATION
Social Security Number*
FULL LEGAL NAME
Last/Surname
First
Middle
Suffix
Birth Date (MM/DD/YYYY)
Gender
 Male  Female
/
/
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
* 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 PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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Section II – Applicant Information – continued
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
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
CURRENT/PRIOR LICENSE INFORMATION
If you currently hold or have previously held a business or professional license/registration in Florida or
elsewhere, please list each one below (attach additional copies of this page as necessary):
Date (From)
Date (To)
1. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
2. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
3. License/Registration Type
State
/
/
/
/
License Number
Name Used
PRIOR NAME INFORMATION
Have you used, been known as, or are currently known by another name (e.g., maiden name or
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/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
DBPR PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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Section III (a) – Background Questions
BACKGROUND QUESTIONS
 Yes
1.
Have you ever been convicted or found guilty of, or entered a plea of
(If yes, please
No
nolo contendere or guilty to, regardless of adjudication, a crime in any
complete
jurisdiction, or are you currently under criminal investigation? This
Section III (b))
question applies to any criminal violation of the laws of any municipality,
county, state or nation, including felony, misdemeanor and traffic
offenses (but not parking, speeding, inspection, or traffic signal
violations), without regard to whether you were placed on probation, had
adjudication withheld, were paroled, or pardoned. If you intend to
answer “NO” because you believe those records have been expunged
or sealed by court order pursuant to Section 943.0585 or 943.059,
Florida Statutes, or applicable law of another state, you are responsible
for verifying the expungement or sealing prior to answering "NO."
YOUR ANSWER TO THIS QUESTION MAY BE CHECKED AGAINST
LOCAL, STATE AND FEDERAL RECORDS. FAILURE TO ANSWER
THIS QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR
REVOCATION OF YOUR LICENSE. IF YOU DO NOT FULLY
UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY
OR CONTACT THE DEPARTMENT.
 Yes
2.
Has any judgment or decree of a court been entered against you in this
No
(If yes, please
or any other state, province, district, territory, possession or nation,
complete
related to the practice or profession for which you are applying, or is
Section III (b))
there any such case or investigation pending?
 Yes
 No
3.
Have you ever had an application for registration, certification, or
(If yes, please
licensure in Florida or in any other jurisdiction denied, or is there now
complete
pending a proceeding or investigation to deny such an application?
Section III (c))
 Yes
 No
4.
Has any license, registration, or permit to practice any regulated
(If yes, please
profession, occupation, vocation, or business been revoked, annulled,
complete
suspended, relinquished, surrendered, or otherwise disciplined in
Section III (c))
Florida or in any other jurisdiction, or is any such proceeding or
investigation now pending?
If you answered “YES” to any question in questions 1-4 above, please refer to Section 2(c) of Instructions
for detailed instructions for providing complete explanations, including requirements for submitting
supporting legal documents. Please complete Section III (b) for your response to questions 1 and 2, and
complete Section III (c) for your response to questions 3 and 4. If you have more than two offenses to
document in Section III (b), or more than one offense to document in Section III (c), attach additional
pages as necessary.
Section III (b) – Explanation(s) for Background Questions 1 and 2
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
 Yes  No
/
/
Description
DBPR PG 4705 Application for License from Null and Void (Expired License)
Incorporated by Rule: 61-35.021 2016 June
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