Form DBPR PG4703 "Application for Reexamination for Professional Geologist" - Florida

What Is Form DBPR PG4703?

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 September 1, 2015;
  • 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 PG4703 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 PG4703 "Application for Reexamination for Professional Geologist" - Florida

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1 of 2
State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for Reexamination for Professional Geologist
Form # DBPR PG 4703
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all portions of this application.
Reexamination for Professional
 Pay $250 fee (Make check payable to Department of
Geologist or Upgrade from GIT in
Business and Professional Regulation).
Another State to Professional
Geologist
 Complete all portions of this application.
Reexamination for Upgrade from
 Pay $115 fee (Make check payable to Department of
GIT in Florida to Professional
Business and Professional Regulation).
Geologist
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.
Application Instructions (by section)
a. Section I
i.
Applicant must select the box indicating which type of reexamination .
ii.
Applicant must select which part of the examination to be taken.
b. Section II
i.
Fill out each section completely.
ii.
Applicant must list their Social Security number.
iii.
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.
iv.
Applicant must provide their email address and telephone number in the appropriate
spaces.
v.
Applicant must provide their complete mailing address.
vi.
Applicant must sign the affirmation by written declaration.
vii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
c. Section III
i.
Applicant must sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
Applications for reexamination and payment of all fees must be received by the Department no later than
90 days prior to the administration date of the licensure examination for which the applicant wishes to sit.
DBPR PG 4703 Application for Reexamination
Eff. Date September 2015
Incorporated by Rule: 61-35.021
1 of 2
State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for Reexamination for Professional Geologist
Form # DBPR PG 4703
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Complete all portions of this application.
Reexamination for Professional
 Pay $250 fee (Make check payable to Department of
Geologist or Upgrade from GIT in
Business and Professional Regulation).
Another State to Professional
Geologist
 Complete all portions of this application.
Reexamination for Upgrade from
 Pay $115 fee (Make check payable to Department of
GIT in Florida to Professional
Business and Professional Regulation).
Geologist
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.
Application Instructions (by section)
a. Section I
i.
Applicant must select the box indicating which type of reexamination .
ii.
Applicant must select which part of the examination to be taken.
b. Section II
i.
Fill out each section completely.
ii.
Applicant must list their Social Security number.
iii.
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.
iv.
Applicant must provide their email address and telephone number in the appropriate
spaces.
v.
Applicant must provide their complete mailing address.
vi.
Applicant must sign the affirmation by written declaration.
vii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
c. Section III
i.
Applicant must sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
Applications for reexamination and payment of all fees must be received by the Department no later than
90 days prior to the administration date of the licensure examination for which the applicant wishes to sit.
DBPR PG 4703 Application for Reexamination
Eff. Date September 2015
Incorporated by Rule: 61-35.021
2 of 2
State of Florida
Department of Business and Professional Regulation
Board of Professional Geologists
Application for Reexamination
Form # DBPR PG 4703
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 TYPE
 Application for Reexamination for Professional Geologist
[5301/1011]
 Application for Reexamination for Upgrade from GIT in Another State to Professional Geologist (Part II
Only)
[5301/1011]
 Application for Reexamination for Upgrade from GIT in Florida to Professional Geologist (Part II Only)
[5301/1015]
EXAMINATION INFORMATION
 Part I Only: Fundamentals of Geology
Please specify examination Part(s) to be
 Part II Only: Practice of Geology
taken:
 Parts I & II: Fundamentals of Geology & Practice of Geology
Section II – Applicant Information
APPLICANT INFORMATION
Social Security Number*
Last/Surname
First
Middle
Suffix
Email Address:
Phone Number:
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code
County (if Florida address)
Country
* 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 PG 4703 Application for Reexamination
Eff. Date September 2015
Incorporated by Rule: 61-35.021
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