Form FDACS-16023 "Affidavit of Experience" - Florida

What Is Form FDACS-16023?

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 October 1, 2016;
  • 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 printable version of Form FDACS-16023 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-16023 "Affidavit of Experience" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Licensing
AFFIDAVIT OF EXPERIENCE
Chapter 493, Florida Statutes
Rule 5N-1.100, Florida Administrative Code
NICOLE "NIKKI" FRIED
Post Office Box 5767sTallahassee, FL 32314-5767s(850) 245-5691
COMMISSIONER
www.mylicensesite.com
Section 493.6105, F.S. requires the applicant for a Class “C” Private Investigator license, a Class “E” Recovery Agent license,
or a Class “M”, “MA”, “MB”, and “MR” Manager license to “include a statement on a form provided by the department of the
experience he or she believes will qualify him or her for such license.”
INSTRUCTIONS: Fill out this form completely, providing complete and comprehensive details about the duties you performed.
Do not sign the form until you are in the presence of a Notary Public. If you have been honorably discharged from military service
and would like to use related military experience toward satisfaction of the experience requirement, attach a copy of your DD214
to this completed form. Mail your completed form with your application to the P.O. Box referenced above.
EXPERIENCE WHICH CANNOT BE VERIFIED BY THE DIVISION OF LICENSING OR EXPERIENCE WHICH WAS ACQUIRED
UNLAWFULLY WILL NOT BE COUNTED TOWARD THE EXPERIENCE REQUIREMENT OUTLINED UNDER CHAPTER 493,
FLORIDA STATUTES.
LAST NAME
FIRST NAME
MI
If you are an alien, you must
SOCIAL SECURITY NUMBER
ALIEN REGISTRATION NUMBER
SEE REVERSE.
also provide your 8- or 9-
A
digit Alien Registration Number.
TYPE OF LICENSE for which you are applying
COMPLETE ONE. If you are applying for more than one class of agency license, a separate Affidavit of Experience form is required for each.
“C”
“MA”
CLASS
PRIVATE INVESTIGATOR LICENSE
CLASS
PRIVATE INVESTIGATIVE AGENCy MANAGER
“E”
“MB”
CLASS
RECOVERy AGENT LICENSE
CLASS
SECURITy AGENCy MANAGER
“M”
“MR”
CLASS
PRIVATE INVESTIGATIVE AND SECURITy BRANCH MANAGER
CLASS
RECOVERy AGENCy MANAGER
APPLICANT INFORMATION (
)
related experience
NAME OF EMPLOYER:
Phone #:
(
)
include area code
ADDRESS:
CITY, STATE ZIP CODE:
JOB TITLE:
DATES OF EMPLOYMENT:
(
/
)
(
/
)
from
mm
yy
to
mm
yy
EXACT DUTIES WHICH RELATE TO THE LICENSE SOUGHT AND PERCENTAGE OF TIME DEVOTED TO THESE DUTIES. BE SPECIFIC:
NAME AND TITLE OF INDIVIDUAL WHO CAN VERIFY EMPLOYMENT:
PHONE NUMBER:
(
)
include area code
FDACS-16023 Rev. 10/16
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Licensing
AFFIDAVIT OF EXPERIENCE
Chapter 493, Florida Statutes
Rule 5N-1.100, Florida Administrative Code
NICOLE "NIKKI" FRIED
Post Office Box 5767sTallahassee, FL 32314-5767s(850) 245-5691
COMMISSIONER
www.mylicensesite.com
Section 493.6105, F.S. requires the applicant for a Class “C” Private Investigator license, a Class “E” Recovery Agent license,
or a Class “M”, “MA”, “MB”, and “MR” Manager license to “include a statement on a form provided by the department of the
experience he or she believes will qualify him or her for such license.”
INSTRUCTIONS: Fill out this form completely, providing complete and comprehensive details about the duties you performed.
Do not sign the form until you are in the presence of a Notary Public. If you have been honorably discharged from military service
and would like to use related military experience toward satisfaction of the experience requirement, attach a copy of your DD214
to this completed form. Mail your completed form with your application to the P.O. Box referenced above.
EXPERIENCE WHICH CANNOT BE VERIFIED BY THE DIVISION OF LICENSING OR EXPERIENCE WHICH WAS ACQUIRED
UNLAWFULLY WILL NOT BE COUNTED TOWARD THE EXPERIENCE REQUIREMENT OUTLINED UNDER CHAPTER 493,
FLORIDA STATUTES.
LAST NAME
FIRST NAME
MI
If you are an alien, you must
SOCIAL SECURITY NUMBER
ALIEN REGISTRATION NUMBER
SEE REVERSE.
also provide your 8- or 9-
A
digit Alien Registration Number.
TYPE OF LICENSE for which you are applying
COMPLETE ONE. If you are applying for more than one class of agency license, a separate Affidavit of Experience form is required for each.
“C”
“MA”
CLASS
PRIVATE INVESTIGATOR LICENSE
CLASS
PRIVATE INVESTIGATIVE AGENCy MANAGER
“E”
“MB”
CLASS
RECOVERy AGENT LICENSE
CLASS
SECURITy AGENCy MANAGER
“M”
“MR”
CLASS
PRIVATE INVESTIGATIVE AND SECURITy BRANCH MANAGER
CLASS
RECOVERy AGENCy MANAGER
APPLICANT INFORMATION (
)
related experience
NAME OF EMPLOYER:
Phone #:
(
)
include area code
ADDRESS:
CITY, STATE ZIP CODE:
JOB TITLE:
DATES OF EMPLOYMENT:
(
/
)
(
/
)
from
mm
yy
to
mm
yy
EXACT DUTIES WHICH RELATE TO THE LICENSE SOUGHT AND PERCENTAGE OF TIME DEVOTED TO THESE DUTIES. BE SPECIFIC:
NAME AND TITLE OF INDIVIDUAL WHO CAN VERIFY EMPLOYMENT:
PHONE NUMBER:
(
)
include area code
FDACS-16023 Rev. 10/16
Page 1 of 2
APPLICANT INFORMATION (
)
related experience
continued
NAME OF EMPLOYER:
Phone #:
(
)
include area code
ADDRESS:
CITY, STATE ZIP CODE:
JOB TITLE:
DATES OF EMPLOYMENT:
(
/
)
(
/
)
from
mm
yy
to
mm
yy
EXACT DUTIES WHICH RELATE TO THE LICENSE SOUGHT AND PERCENTAGE OF TIME DEVOTED TO THESE DUTIES. BE SPECIFIC:
NAME AND TITLE OF INDIVIDUAL WHO CAN VERIFY EMPLOYMENT:
PHONE NUMBER:
(
)
INCLUDE AREA CODE
NAME OF EMPLOYER:
Phone #:
(
)
include area code
ADDRESS:
CITY, STATE ZIP CODE:
JOB TITLE:
DATES OF EMPLOYMENT:
(
/
)
(
/
)
from
mm
yy
to
mm
yy
EXACT DUTIES WHICH RELATE TO THE LICENSE SOUGHT AND PERCENTAGE OF TIME DEVOTED TO THESE DUTIES. BE SPECIFIC:
NAME AND TITLE OF INDIVIDUAL WHO CAN VERIFY EMPLOYMENT:
PHONE NUMBER:
(
)
INCLUDE AREA CODE
I,
, do hereby swear or affirm
that the work experience listed herein accurately reflects my employment history and the job duties I have performed, and
that this work experience is related to the license for which I have applied.
S
a
d
S
ignature of
pplicant
ate
igned
STATE OF FLORIDA
COUNTY OF
The foregoing application was sworn to (or affirmed) and subscribed before me this
day of
, 20
by:
print
name of applicant
notary Signature
p
p
erSonally known
roduced identification
,
,
print
type
or Stamp name of notary
T
I
p
ype of
denTIfIcaTIon
roduced
USE OF SOCIAL SECURITY NUMBERS: Sections 493.6105, 493.6304, and 493.6406, Florida Statutes (F. S.), in conjunction with section 119.071(5) (a) 2, F. S.,
mandates that the Department of Agriculture and Consumer Services, Division of Licensing, obtain social security numbers from applicants. Applicant social security
numbers are maintained and used by the Division of Licensing for identification purposes, to prevent misidentification, and to facilitate the approval process by the
Division. The Department of Agriculture and Consumer Services, Division of Licensing, will not disclose an applicant’s social security number without consent of the
applicant to anyone outside of the Department of Agriculture and Consumer Services, Division of Licensing, or as required by law. [See Chapter 119, F. S., 15 U.S.C.
ss. 1681 et seq., 15 U.S.C. ss. 6801 et seq., 18 U.S.C. ss. 2721 et seq., Pub. L. No. 107-56 (USA Patriot Act of 2001), and Presidential Executive Order 13224.]
FDACS-16023 Rev. 10/16
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