"Change of Status Application" - Florida

Change of Status Application is a legal document that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida.

Form Details:

  • Released on September 1, 2015;
  • The latest edition currently provided by the Florida Department of Business & Professional Regulation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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State of Florida
Department of Business and Professional Regulation
Mold Related Services
Change of Status Application
Form # DBPR MRS 0702
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Fee of $200. Make check payable to the Florida Department of Business
and Professional Regulation.
 Complete Section I-IV of the application, which includes attesting to
Set to Active
compliance with the insurance requirements.
 Submit credit for 14 hours of continuing education (if required).
 Fee of $100. Make check payable to the Florida Department of Business
Set to Inactive
and Professional Regulation.
 Complete Sections I, II and IV of the application.
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.
1. Application Instructions (by Section)
a. Section I- Application Type
i.
Set to Active: This transaction is used to request that the license be reactivated.
ii.
Set to Inactive: This transaction is used to request that the license be deactivated.
b. Section II- Licensee Information
i.
Fill out each section completely.
ii.
In the Full Legal Name section provide your full legal name as it appears on your license.
Do not use any nicknames or initials. Please provide license number.
iii.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
iv.
Contact information is often used to quickly resolve questions with applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
c. Section III – Proof of Insurance
i.
If you are applying for an “active status” license, you must have at least the minimum
amount of insurance required. A mold assessor is required to have $1,000,000 general
liability and $1,000,000 Errors and Omissions for both preliminary and post-remediation
mold assessment. A mold remediator is required to have $1,000,000 of general liability
insurance that includes specific coverage for mold-related claims.
d. Section V- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR MRS 0702 Change of Status Application
Eff. Date September 2015
Incorporated by Rule: 61-35.028
1 of 3
State of Florida
Department of Business and Professional Regulation
Mold Related Services
Change of Status Application
Form # DBPR MRS 0702
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
TRANSACTION
APPLICATION REQUIREMENTS
 Fee of $200. Make check payable to the Florida Department of Business
and Professional Regulation.
 Complete Section I-IV of the application, which includes attesting to
Set to Active
compliance with the insurance requirements.
 Submit credit for 14 hours of continuing education (if required).
 Fee of $100. Make check payable to the Florida Department of Business
Set to Inactive
and Professional Regulation.
 Complete Sections I, II and IV of the application.
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.
1. Application Instructions (by Section)
a. Section I- Application Type
i.
Set to Active: This transaction is used to request that the license be reactivated.
ii.
Set to Inactive: This transaction is used to request that the license be deactivated.
b. Section II- Licensee Information
i.
Fill out each section completely.
ii.
In the Full Legal Name section provide your full legal name as it appears on your license.
Do not use any nicknames or initials. Please provide license number.
iii.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
iv.
Contact information is often used to quickly resolve questions with applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
c. Section III – Proof of Insurance
i.
If you are applying for an “active status” license, you must have at least the minimum
amount of insurance required. A mold assessor is required to have $1,000,000 general
liability and $1,000,000 Errors and Omissions for both preliminary and post-remediation
mold assessment. A mold remediator is required to have $1,000,000 of general liability
insurance that includes specific coverage for mold-related claims.
d. Section V- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR MRS 0702 Change of Status Application
Eff. Date September 2015
Incorporated by Rule: 61-35.028
2 of 3
State of Florida
Department of Business and Professional Regulation
Mold Related Services
Change of Status Application
Form # DBPR MRS 0702
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 TYPES (Check one)
Set to Active:
Set to Inactive:
Mold Assessor (0701/3020)
Mold Assessor (0701/4020)
Mold Remediator (0702/3020)
Mold Remediator (0702/4020)
Section II – Licensee Information
LICENSEE INFORMATION
Last/Surname
First
Middle
License Number
*Social Security Number
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
E-Mail Address
Phone Number
Please be advised that an inactive license will prohibit you from acting as a licensed Assessor or Remediator under
any and all circumstances in this state. If you wish to return to active status, you must request reactivation, pay all
applicable reactivation and renewal fees, and comply with all applicable license renewal requirements. An inactive
license is required to complete all required continuing education requirements as a condition of license renewal. Any
Assessor or Remediator working on an inactive license is subject to disciplinary action.
* 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 MRS 0702 Change of Status Application
Eff. Date September 2015
Incorporated by Rule: 61-35.028
3 of 3
Section III – Proof of Insurance
INSURANCE
If the applicant has NOT obtained liability insurance at minimum requirements the applicant is
only eligible for an Inactive license.
Mold Assessor: Have you obtained general liability and errors and omission for preliminary and post
remediation mold assessment insurance coverage in the amounts of:
Minimum amounts required for:
General liability - $1,000,000
Errors and omission - $1,000,000
Yes
Mold Remediator: Have you obtained general liability including coverage for mold related claims in the
amount of:
Minimum amounts required for:
General liability - $1,000,000
Yes 
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:
DBPR MRS 0702 Change of Status Application
Eff. Date September 2015
Incorporated by Rule: 61-35.028
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