Form DBPR LA 2 Application for Licensure of a Business Entity: Certificate of Authorization - Florida

Form DBPR LA2 is a Florida Department of Business & Professional Regulation form also known as the "Application For Licensure Of A Business Entity: Certificate Of Authorization". The latest edition of the form was released in July 10, 2012 and is available for digital filing.

Download a PDF version of the Form DBPR LA2 down below or find it on Florida Department of Business & Professional Regulation Forms website.

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State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Licensure of a Business Entity: Certificate of Authorization
Form # DBPR LA 2
APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 Submit the $455 fee (make check payable to the Department of Business
Certificate of
and Professional Regulation).
Authorization
 Attach any applicable additional documentation (i.e. additional officers or
registered landscape architects, etc.)
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
Incorporated by Rule: 61-35.017
Eff. date: 07/10/2012
DBPR LA 2 Certificate of Authorization Application
1 of 6
State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Licensure of a Business Entity: Certificate of Authorization
Form # DBPR LA 2
APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Complete all sections of this application.
 Submit the $455 fee (make check payable to the Department of Business
Certificate of
and Professional Regulation).
Authorization
 Attach any applicable additional documentation (i.e. additional officers or
registered landscape architects, etc.)
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
Incorporated by Rule: 61-35.017
Eff. date: 07/10/2012
DBPR LA 2 Certificate of Authorization Application
2 of 6
State of Florida
Department of Business and Professional Regulation
Board of Landscape Architecture
Application for Licensure of a Business Entity: Certificate of Authorization
Form # DBPR LA 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.
For fees additional information see the instructions at the end of this application.
Section I – Applicant Business Entity Qualifier Information
QUALIFIER PERSONAL INFORMATION
(application MUST be completed and signed by qualifier)
Name
DBPR License #
Address
City
State
Zip
Phone #
Position Title (Qualifier MUST be a principal officer – see Instructions for details)
Section II – Applicant Business Entity Information
ORGANIZATION INFORMATION
Federal Employer ID Number and/or Social Security Number*
Organization/Applicant Name
Doing Business As (D/B/A) Name
Ownership:  Corporation  Partnership  LLC  Non-Profit Other:
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Contact Name
Primary Phone Number
Primary E-Mail Address
BUSINESS LOCATION ADDRESS
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
*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: 07/10/2012
DBPR LA 2 Certificate of Authorization Application
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Section II – Applicant Business Entity Information - continued
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
OFFICER(S)/PARTNER(S)
Identify each officer/partner of the applicant business entity who is a registered landscape architect in
the state of Florida. Do not list officers or partners who are not registered landscape architects (attach
additional pages as necessary):
1. Name
DBPR License #
Principal Officer?
 Yes
 No
Address
City
State
Zip
2. Name
DBPR License #
Principal Officer?
 Yes
 No
Address
City
State
Zip
3. Name
DBPR License #
Principal Officer?
 Yes
 No
Address
City
State
Zip
Section II – Applicant Business Entity Information - continued
BUSINESS INCEPTION/FOUNDING DATES
Date company was registered/filed with the FL Secretary of State (if pending, please acknowledge)
(MM/DD/YY):
Has the company solicited and/or offered landscape architecture services in the State of Florida prior to
being licensed by the Florida board?
 No
 Yes - If yes, list the last three projects with start and end dates wherein the company solicited
for or provided such services:
1. Name of Client
Project Type
Client Address
City
State
Zip
Start Date
End Date
2. Name of Client
Project Type
Client Address
City
State
Zip
Start Date
End Date
3. Name of Client
Project Type
Client Address
City
State
Zip
Start Date
End Date
Incorporated by Rule: 61-35.017
Eff. date: 07/10/2012
DBPR LA 2 Certificate of Authorization Application
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Section III (a) – Background Questions
BACKGROUND QUESTIONS
1. Has this company ever been a defendant in civil or criminal litigation?
 No
 Yes - If yes, complete Section III (b) of this application as appropriate.
2. Has disciplinary action ever been sanctioned by a State regulatory board against the company?
 No
 Yes - If yes, complete Section III (c) of this application. Please note: you will be notified if the
Board requires additional documentation.
Section III (b) – Explanation(s) for Background Question 1
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: 07/10/2012
DBPR LA 2 Certificate of Authorization Application
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Section III (c) – General Explanation for Background Question 2
EXPLANATION
Please provide details of any disciplinary action(s) against the company by a State regulatory
board including, but not limited to, date, description, state, disposition/discipline, and status of
compliance.
Section IV – 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:
Incorporated by Rule: 61-35.017
Eff. date: 07/10/2012
DBPR LA 2 Certificate of Authorization Application

Download Form DBPR LA 2 Application for Licensure of a Business Entity: Certificate of Authorization - Florida

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