Form DBPR HR-7014 "Application for Certificate of Competency and Certified Elevator Technician Registration" - Florida

What Is Form DBPR HR-7014?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - 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 January 1, 2018;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • 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 DBPR HR-7014 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR HR-7014 "Application for Certificate of Competency and Certified Elevator Technician Registration" - Florida

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DBPR HR-7014 – Application for Certificate of Competency and Certified Elevator Technician Registration
STATE OF FLORIDA, DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
Division of Hotels and Restaurants, Bureau of Elevator Safety
2601 Blair Stone Road, Tallahassee, FL 32399-1013
Phone: 850.487.1395 – Email:
www.MyFloridaLicense.com/contactus/
Internet :
www.MyFloridalicense.com/DBPR/elevator-safety/
Please direct questions about this application to the Department of Business and Professional Regulation’s Customer
Contact Center at 850.487.1395.
Section 1 – Application Information
Please check all that apply:
Initial Certificate of Competency (CC)
If qualifying by examination: I have elected to provide proof of completion and successful passage of a written examination
administered by the division or its designee. In electing this option, I authorize the following examination provider to release
.
information to the department for verifying my successful completion of their examination
Examination Provider:
Initial Certificate of Competency (CC) from Null and Void
Florida Certificate of Competency Number (Required):
If qualifying by examination: I have elected to provide proof of completion and successful passage of a written examination
administered by the division or its designee. In electing this option, I authorize the following examination provider to release
.
information to the department for verifying my successful completion of their examination
Examination Provider:
– I am providing required proof of insurance
Certified Elevator Technician (CET) License
.
Florida Certificate of Competency Number (Required, if already hold a CC license):
Section 2 – Personal Information (MA)
Note: This address will be designated as the "address of record" for the license.
* Under the Federal Privacy Act,
Social Security Number (REQUIRED)*
disclosure of Social Security Numbers
is
voluntary
unless
specifically
required by Federal statute. In this
Last Name
First
Middle
Suffix (Jr., III, etc.)
instance, social security numbers are
mandatory pursuant to Title 42 United
States Code, Sections 653 and 654;
and sections 409.2577, 409.2598 and
Birth Date (MM/DD/YYYY)
559.79,
Florida
Statutes.
Social
Security numbers are used to allow
efficient screening of applicants and
licensees by a Title IV-D child support
Street Address or Post Office Box
agency to assure compliance with
child
support
obligations.
Social
Security
numbers
must
also
be
City
recorded on all professional
and
occupational license applications and
will be used for licensee identification
pursuant
to
the
Personal
Florida County
State
Zip Code (+4 optional)
Responsibility and Work Opportunity
Reconciliation Act of 1996 (Welfare
Reform Act), 104 Pub.L.193, Sec 317.
Country
E-Mail Address (Optional)
Phone Number
Section 3 – License Location Information (LL)
Note: This address will be designated as the physical location address for this license.
Street Address
City
Florida County
State
Zip Code (+4 optional)
Country
E-Mail Address (Optional)
Page 1 of 2
2018 January
61C-5.007, F.A.C.
DBPR HR-7014 – Application for Certificate of Competency and Certified Elevator Technician Registration
STATE OF FLORIDA, DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
Division of Hotels and Restaurants, Bureau of Elevator Safety
2601 Blair Stone Road, Tallahassee, FL 32399-1013
Phone: 850.487.1395 – Email:
www.MyFloridaLicense.com/contactus/
Internet :
www.MyFloridalicense.com/DBPR/elevator-safety/
Please direct questions about this application to the Department of Business and Professional Regulation’s Customer
Contact Center at 850.487.1395.
Section 1 – Application Information
Please check all that apply:
Initial Certificate of Competency (CC)
If qualifying by examination: I have elected to provide proof of completion and successful passage of a written examination
administered by the division or its designee. In electing this option, I authorize the following examination provider to release
.
information to the department for verifying my successful completion of their examination
Examination Provider:
Initial Certificate of Competency (CC) from Null and Void
Florida Certificate of Competency Number (Required):
If qualifying by examination: I have elected to provide proof of completion and successful passage of a written examination
administered by the division or its designee. In electing this option, I authorize the following examination provider to release
.
information to the department for verifying my successful completion of their examination
Examination Provider:
– I am providing required proof of insurance
Certified Elevator Technician (CET) License
.
Florida Certificate of Competency Number (Required, if already hold a CC license):
Section 2 – Personal Information (MA)
Note: This address will be designated as the "address of record" for the license.
* Under the Federal Privacy Act,
Social Security Number (REQUIRED)*
disclosure of Social Security Numbers
is
voluntary
unless
specifically
required by Federal statute. In this
Last Name
First
Middle
Suffix (Jr., III, etc.)
instance, social security numbers are
mandatory pursuant to Title 42 United
States Code, Sections 653 and 654;
and sections 409.2577, 409.2598 and
Birth Date (MM/DD/YYYY)
559.79,
Florida
Statutes.
Social
Security numbers are used to allow
efficient screening of applicants and
licensees by a Title IV-D child support
Street Address or Post Office Box
agency to assure compliance with
child
support
obligations.
Social
Security
numbers
must
also
be
City
recorded on all professional
and
occupational license applications and
will be used for licensee identification
pursuant
to
the
Personal
Florida County
State
Zip Code (+4 optional)
Responsibility and Work Opportunity
Reconciliation Act of 1996 (Welfare
Reform Act), 104 Pub.L.193, Sec 317.
Country
E-Mail Address (Optional)
Phone Number
Section 3 – License Location Information (LL)
Note: This address will be designated as the physical location address for this license.
Street Address
City
Florida County
State
Zip Code (+4 optional)
Country
E-Mail Address (Optional)
Page 1 of 2
2018 January
61C-5.007, F.A.C.
DBPR HR-7014 – Application for Certificate of Competency and Certified Elevator Technician Registration
Section 4 – License Mailing Information (LM)
Note: This address will be used by the department for all mailings to the licensee, including the license and license renewal notices.
Routing Name (
)
e.g., Office Manager, contact name
Street Address or Post Office Box
City
Florida County
State
Zip Code (+4 optional)
Country
E-Mail Address (Optional)
Phone Number
Section 5 – Employment Information
Business/Firm Name
Street Address or Post Office Box
City
Florida County
State
Zip Code (+4 optional)
Country
Section 6 – Signature
I acknowledge that:
1. I must possess a valid certificate of competency card and register for a certified elevator technician license
before I may construct, install, maintain, or repair an elevator in Florida.
2. A certificate of competency card and certified elevator technician license registration expires December 31
each year.
3. The certificate of competency may only be renewed by the division upon receipt of proof of successful
completion of eight hours of continuing education as prescribed by rule, payment of the certificate of
competency fee, and satisfaction of any other requirements provided by law.
4. The annual certified elevator technician license registration may only be completed by the division upon
receipt of the registrant’s valid certificate of competency number and proof of comprehensive general liability
insurance coverage as specified by division rule.
SECTION 559.79(2), Florida Statutes: Each application for a license or renewal of a license issued by the Department of
Business and Professional Regulation shall be signed under oath or affirmation by the applicant, or owner or chief
executive of the applicant without the need for witnesses unless otherwise required by law.
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
Complete the application and mail it, the supporting documents, and the required $50 certificate of competency
fee to the address on this form. Please use the entire 9-digit zip code in the address above to ensure proper
handling.
Page 2 of 2
2018 January
61C-5.007, F.A.C.
Page of 2