Form DBPR-LO2 "Business Agent Application" - Florida

What Is Form DBPR-LO2?

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 December 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-LO2 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-LO2 "Business Agent Application" - Florida

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STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
BUSINESS AGENT APPLICATION
DBPR – LO 2
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.
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
APPLICATION REQUIRMENTS
 Pay $25.00 Initial application fee.
 Make check payable to the Department of Business and Professional Regulation
 Complete Business Agent Application
 Complete Labor Organization Application/Annual Report if Organization is not currently registered.
 Submit fingerprints for background investigation taken by an official qualified to take fingerprints.
 Submit documentation to show proof that your civil rights have been restored. (If applicable)
PERSONAL INFORMATION
Social Security Number*
Last Name
First
Middle
Title
Suffix
Birth Date (MM/DD/YYYY)
Gender:
/
/
 Male
 Female
Race/Ethnicity (check only one):
Black or African American
Asian or Pacific Islander
Native American or Alaskan Native
White or Caucasian
Spanish, Hispanic or Latino
Other
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
*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, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers
must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.
Rev. 12/2016
1
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
BUSINESS AGENT APPLICATION
DBPR – LO 2
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.
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
APPLICATION REQUIRMENTS
 Pay $25.00 Initial application fee.
 Make check payable to the Department of Business and Professional Regulation
 Complete Business Agent Application
 Complete Labor Organization Application/Annual Report if Organization is not currently registered.
 Submit fingerprints for background investigation taken by an official qualified to take fingerprints.
 Submit documentation to show proof that your civil rights have been restored. (If applicable)
PERSONAL INFORMATION
Social Security Number*
Last Name
First
Middle
Title
Suffix
Birth Date (MM/DD/YYYY)
Gender:
/
/
 Male
 Female
Race/Ethnicity (check only one):
Black or African American
Asian or Pacific Islander
Native American or Alaskan Native
White or Caucasian
Spanish, Hispanic or Latino
Other
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
*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, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are
used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers
must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.
Rev. 12/2016
1
DBPR LO 2 – BUSINESS AGENT APPLICATION
LABOR ORGANIZATION INFORMATION
Name of Labor Organization
Federal Employer Identification Number
License Number
Union Local Number
BACKGROUND QUESTIONS
1.
Yes
No
Have you ever been convicted of a felony?
If yes, attach a copy of the court records or documents that restored
your civil rights.
2.
Yes
No
Are you being paid by the Labor Organization?
ATTEST STATEMENT
I have read the questions in this application and have answered them completely and truthfully to the best
of my knowledge.
I pledge to comply with the applicable standards of practice upon licensure, registration, or certification.
I understand the types of misconduct for which disciplinary proceedings may be initiated.
Giving knowingly misleading statements or knowing misrepresentation when applying for a license
constitutes a felony of the third degree and may result in licensure denial or revocation.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are true.
Business Agent Signature:
Print Name:
Social Security Number:
MUST BE SIGNED BY THE PRESIDENT AND THE SECRETARY
We, the undersigned of the above Labor Organization, state that the above applicant has been
designated as our business agent and is so authorized as defined by Section 447.02(2), Florida Statutes,
by being duly elected/appointed on this
day of
, 20
.
Print Name of Union President
Signature of Union President
Date
Print Name of Union Secretary
Signature of Union Secretary
Date
2
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