Form DBPR LA5 "Application for Individual Licensure: Reinstate Null and Void License" - Florida

What Is Form DBPR LA5?

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 printable version of Form DBPR LA5 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 LA5 "Application for Individual Licensure: Reinstate Null and Void License" - Florida

1496 times
Rate (4.7 / 5) 75 votes
1 of 7
State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Individual Licensure: Reinstate Null and Void License
Form # DBPR LA 5
APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
Complete this application.
Submit the $450 reinstatement fee (make check payable to the Department
Reinstatement of
of Business and Professional Regulation or DBPR).
Null and Void
Submit proof of a minimum of 16 hours of continuing education credit.
License
Please visit
www.myfloridalicense.com/dbpr/pro/larch/index.html
to view
information regarding continuing education.
Please send your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
1 of 7
State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Individual Licensure: Reinstate Null and Void License
Form # DBPR LA 5
APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
Complete this application.
Submit the $450 reinstatement fee (make check payable to the Department
Reinstatement of
of Business and Professional Regulation or DBPR).
Null and Void
Submit proof of a minimum of 16 hours of continuing education credit.
License
Please visit
www.myfloridalicense.com/dbpr/pro/larch/index.html
to view
information regarding continuing education.
Please send your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
2 of 7
State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Individual Licensure: Reinstate Null and Void License
Form # DBPR LA 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 - Applicant Personal Information
PERSONAL 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
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
PRIOR NAME INFORMATION
Have you used, been known as, or been called by another name (example - maiden name, 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
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In
*
this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Section 653, 654, and 666(a); and
Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers must be recorded on all professional and
occupational license applications and will be used to allow efficient screening of applicants and licensees by Title IV-D Child Support
Agency to assure compliance with child support obligations.
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
3 of 7
Section I - Applicant Personal Information - continued
CURRENT/PRIOR LICENSE INFORMATION
If you currently hold or have previously held a business or professional license/registration in Florida or
elsewhere, please list them below (attach additional copies if 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
Section II (a) – Background Questions
BACKGROUND QUESTIONS
1.
 Yes
 No
Have you ever been convicted or found guilty of, or entered a plea of nolo
(If yes, please
contendere to, regardless of adjudication, a crime in any jurisdiction, or
complete
are you currently under criminal investigation? This question applies to
Section II (b))
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.
2.
 Yes
 No
Has any judgment or decree of a court been entered against you in this or
(If yes, please
any other state, province, district, territory, possession or nation, related
complete
to the practice or profession for which you are applying, or is there any
Section II (b))
such case or investigation pending?
3.
 Yes
 No
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 II (c))
4.
 Yes
 No
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 Florida
Section II (c))
or in any other jurisdiction, or is any such proceeding or investigation now
pending?
If you answered “YES” to questions 1 – 4 above, please provide the full details of any criminal conviction, lawsuit or
judgment, or 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. Please
complete Section II (b) for your response to questions 1 and 2, and complete Section II (c) for your response to
questions 3 and 4. If you have more than three offenses to document in Section II (b), attach additional copies as
necessary.
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
4 of 7
Section II (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
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
5 of 7
Section II (c) – Explanation(s) for Background Questions 3 and 4
EXPLANATION
Incorporated by Rule: 61-35.017
Eff. date: October, 2012
DBPR LA 5 Reinstate Null and Void License
Page of 7