Form FDACS-10056 "Board of Professional Surveyors and Mappers Continuing Education Provider Approval Application" - Florida

What Is Form FDACS-10056?

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 August 1, 2017;
  • 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-10056 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-10056 "Board of Professional Surveyors and Mappers Continuing Education Provider Approval Application" - Florida

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FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
NICOLE "NIKKI" FRIED
COMMISSIONER
BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS
CONTINUING EDUCATION PROVIDER APPROVAL APPLICATION
Chapter 472, Florida Statutes
Rule 5J-17.043, Florida Administrative Code
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
NICOLE "NIKKI" FRIED
COMMISSIONER
BOARD OF PROFESSIONAL SURVEYORS AND MAPPERS
CONTINUING EDUCATION PROVIDER APPROVAL APPLICATION
Chapter 472, Florida Statutes
Rule 5J-17.043, Florida Administrative Code
Florida Department of Agriculture and Consumer Services
Board of Professional Surveyors and Mappers
Continuing Education Provider Approval Application
If you have any questions or need assistance in completing this application, please contact the Florida Department of
Agriculture and Consumer Services at 1-800-HELP-FLA (435-7352) or (850) 410-3800.
In filing an application, be certain that the application is completely filled out, that all questions are answered truthfully and
that all the information requested is furnished. Please type or print in ink. Applicants are cautioned to read questions
thoroughly.
Provider approval does not constitute automatic course approval.
APPLICATION REQUIREMENTS
Provider Application
Submit this application along with a non-refundable application fee of $200, in
addition to a $250 fee for continuing education provider status. Make your $450
check payable to the Florida Department of Agriculture and Consumer Services
(FDACS).
Complete this application and submit a copy of the proposed course completion
certificate.
Provider Renewal
Submit this application along with your required $250 fee. Make your check payable
to the Florida Department of Agriculture and Consumer Services (FDACS).
Complete this application and submit a copy of the proposed course completion
certificate.
General Information
SAMPLE CERTIFICATE OF COMPLETION
Attach a sample of the certificate of completion for the course or seminar that will be distributed to the licensees.
The certificate must contain the provider name and number, course or seminar number, licensee’s name, license
number and the date(s) of attendance.
PROVIDER AND COURSE NAME
The provider and course name must be used on all correspondence, advertisements, etc. It is the provider’s
responsibility to resolve any conflicts over reporting problems.
All providers of continuing education must comply with the requirements in Rule 5J-17.044(6), F.A.C., and submit
an electronic course roster to the department within 30 business days upon course completion.
Please send your completed application, documentation and required fee(s) to:
FDACS
Surveyors and Mappers
PO Box 6700
Tallahassee, FL 32314-6700
FDACS–10056 Rev.08/17
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
BOARD OF PROFESSIONAL
Submit and Pay Online at:
www.FDACS.gov
SURVEYORS AND MAPPERS
- or -
CONTINUING EDUCATION PROVIDER
Check or Money Order payable to
APPROVAL APPLICATION
FDACS and remit with application
to:
Chapter 472, Florida Statutes
Rule 5J-17.043, Florida Administrative Code
FDACS
NICOLE "NIKKI" FRIED
PO Box 6700
1-800-HELP-FLA (435-7352) • (850) 410-3800
Tallahassee, FL 32314-6700
COMMIS SIONER
www.FDACS.gov • (850) 410-3804 Fax
Note: All documents and attachments submitted with this application are subject to public review pursuant to Chapter 119, F.S.
APPLICATION TYPE
Provider Initial Application ($450 Fee)
Provider Renewal ($250 Fee)
(non-refundable application fee of $200 and $250 provider status fee)
PROVIDER INFORMATION
Individual / Company Name:
Provider Number:
Federal Employer ID Number (FEID) or Social Security Number (SSN):
**
Point of Contact:
Mailing Address (if applicable please include suite and/or unit numbers):
City:
State:
Zip Code:
-
Email Address:
Website:
Contact Number(s):
-
(
)
-
(
)
-
(
)
Telephone
Facsimile
Provider Number (if applicable)
OWNERSHIP INFORMATION
Individual / Company Name:
FEIN or SSN:
Street Address (if applicable please include suite and/or unit numbers):
City:
State:
Zip Code:
-
Email Address:
Website:
Contact Number(s):
Org Code: 42 10 08 01 000
EO: A2
(
)
-
(
)
-
Object Code: 001261
$450 / 250
Telephone
Alternate Number
** Under the Federal Privacy Act, disclosure of Social Security Numbers is voluntary, unless specifically required
by federal statute. Social Security numbers must be recorded on all professional license applications and will be
used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, 104 Pub.L. 193, Sec 317. Social Security numbers will be used to allow efficient screening of applicants
and licensees by a Title IV-D child support agency to assure compliance with child support obligations. As such,
disclosure of your Social Security number is required on this application under Sections 409.2577, 409.2598,
and 472. 015, Florida Statutes. Social Security numbers are not a public record under Florida law.
FDACS–10056 Rev. 08/17
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PROVIDER QUALIFICATION
Please check all that apply:
I am a
A surveyor with a Florida license to practice surveying who is not under disciplinary restrictions.
A vendor of equipment or software used in the practice of surveying and mapping.
Employed by a regionally accredited educational institution.
A commercial educator.
A member of state or national professional association whose primary purpose is to promote the profession.
COURSE / SEMINAR DESCRIPTION
Describe in detail the types of courses or seminars you expect to conduct as a Continuing Education Provider.
NOTE: Attach a copy of the proposed course completion certificate.
REQUIRES SIGNATURE OF PROVIDER POINT OF CONTACT
I have provided the above information completely and truthfully to the best of my knowledge.
Applicant Signature: ______________________________________________ Date: __________________
FDACS–10056 Rev. 08/17
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