Form FDACS-03578 "Lp Gas Category I Dealer License Application" - Florida

What Is Form FDACS-03578?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - 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 May 1, 2019;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • 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 fillable version of Form FDACS-03578 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-03578 "Lp Gas Category I Dealer License Application" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Check or Money Order payable
to FDACS and remit with
application to:
LP GAS CATEGORY I
DEALER LICENSE APPLICATION
FDACS
P.O. Box 6700Tallahassee, FL
NICOLE “NIKKI” FRIED
32314-6700
Chapter 527, Florida Statutes
COMMISSIONER
Rule 5J-20.004, Florida Administrative Code
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license application
fee, to the Bureau of Compliance [(850) 921-1600] at the address in the upper right-hand corner.
Business Name or DBA
Company Name or Corporation:
(Name to be printed on license):
Physical Address
:
Company Mailing Address:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE.
Pursuant to Section 527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage liability
covering the products and operations of the business is required. A $1,000,000 surety bond may be submitted in lieu of the
required proof of insurance.
MINIMUM STORAGE: By signing below, I certify that I meet the minimum storage requirement per Section 527.11, F.S.
Signature of Owner/Manager __________________________________
Date _______________________
Signature of Wholesaler/Agent ________________________________
Date _______________________ (If applicable)
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS–03578 05/19
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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Check or Money Order payable
to FDACS and remit with
application to:
LP GAS CATEGORY I
DEALER LICENSE APPLICATION
FDACS
P.O. Box 6700Tallahassee, FL
NICOLE “NIKKI” FRIED
32314-6700
Chapter 527, Florida Statutes
COMMISSIONER
Rule 5J-20.004, Florida Administrative Code
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license application
fee, to the Bureau of Compliance [(850) 921-1600] at the address in the upper right-hand corner.
Business Name or DBA
Company Name or Corporation:
(Name to be printed on license):
Physical Address
:
Company Mailing Address:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE.
Pursuant to Section 527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage liability
covering the products and operations of the business is required. A $1,000,000 surety bond may be submitted in lieu of the
required proof of insurance.
MINIMUM STORAGE: By signing below, I certify that I meet the minimum storage requirement per Section 527.11, F.S.
Signature of Owner/Manager __________________________________
Date _______________________
Signature of Wholesaler/Agent ________________________________
Date _______________________ (If applicable)
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS–03578 05/19
Page 1 of 2
QUALIFIERS: List the names and certificate numbers of all qualifiers employed by this company below. Attach a separate sheet
if necessary. A separate qualifier is required for every 10 employees.
Indicate number of employees at this location: ____________________
NAME
CERTIFICATE NUMBER
1.
2.
3.
MASTER QUALIFIER: Must function as the owner, manager, or person primarily responsible for overseeing the operations
of the location to be licensed.
I HAVE READ THE ABOVE STATEMENT AND VERIFY THAT I MEET THE ABOVE MASTER QUALIFIER CONDITIONS
Signature of Master Qualifier__________________________________________________________________________
Master Qualifier Name:
Certificate Number:
Date of expiration:
All bulk delivery vehicles must be registered with the department at time of application for licensure or when placed
into service. Please list below truck tag number, tank serial number and tank manufacturer of all bulk delivery
vehicles owned or leased. Please EXCLUDE any previously registered vehicles. Attach additional sheets (if
necessary).
Truck Tag Number
Tank Serial Number
Truck Manufacturer
Has the owner/applicant been convicted or pled nolo contendere to a felony as defined in Rule 5J-20.005, F.A.C.,
within the last five years? If yes, please explain.
NO
YES
_____________________________________________________________
PRINT NAME OF OWNER/APPLICANT:
SIGNATURE OF OWNER/APPLICANT:
NAME OF PERSON PREPARING APPLICATION:
PREPARER’S PHONE NO:
PREPARER’S EMAIL ADDRESS:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
FDACS–03578 05/19
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