DBPR HR-7014 – Division of Hotels and Restaurants, Bureau of Elevator Safety
Application for Certificate of Competency
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
1940 North Monroe Street
Tallahassee, FL 32399-0783
Phone: 850.487.1395 – E-mail: dhr.elevators@dbpr.state.fl.us
www.MyFloridaLicense.com/dbpr/hr
For Bureau Use Only
CC#
Please direct questions about this application to the Department of Business and Professional Regulation’s Customer
Contact Center at 850.487.1395. Information is also available online at www.MyFloridaLicense.com/dbpr/hr/.
SECTION 1 – CERTIFICATE TYPE
Certificate of Competency
Certificate of Competency – Wheelchair Lift Only
SECTION 2 – PERSONAL INFORMATION
Social Security Number*
Last Name
First
Title
Middle
Birth Date (MM/DD/YYYY)
Race/Ethnicity (check only one--optional):
Black or African American
White or Caucasian
Asian or Pacific Islander
Spanish, Hispanic or Latino
MAILING ADDRESS
Suffix (Mr., Ms., etc.)
Gender (optional)
Male
Female
Native American or Alaskan Native
Other
Street Address or Post Office Box
City
State
County (if Florida address)
Zip Code (+4 optional)
Country
CONTACT INFORMATION
Primary E-Mail Address
Primary Phone Number
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
County (if Florida address)
State
Zip Code (+4 optional)
State
Zip Code (+4 optional)
Country
BUSINESS LOCATION ADDRESS
Business/Firm Name
Street Address
City
County (if Florida address)
Country
* Under the Federal Privacy Act, disclosure of Social Security Numbers is voluntary unless specifically required by Federal statute. In this instance, social
security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and sections 455.203(9) 409.2577, and 409.2598,
Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure
compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and
will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104
Pub.L.193, Sec 317.
2009 October 14
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DBPR HR-7014 – Division of Hotels and Restaurants, Bureau of Elevator Safety
Application for Certificate of Competency
SECTION 3 - SIGNATURE
I am applying for the Elevator Certificate of Competency card. I swear or affirm that I have successfully
passed an examination administered by a source approved by the Department of Business and Professional
Regulation pursuant to Chapter 399, Florida Statutes, or have completed one of the other prerequisites. I
have attached proof of my successful completion of the examination or other prerequisite and a check or
Money Order for $50 to this form.
Examination Provider
I further acknowledge that:
1. A certificate of competency expires December 31 of the current year.
2. The certificate of competency may only be renewed by the division upon receipt of an Annual Registration
form, proof of successful completion of eight hours of continuing education as prescribed by rule, payment
of a renewal fee, and satisfaction of any other requirements provided by law.
I HEREBY swear or affirm that all statements made on this application are true. I further certify that I maintain liability
insurance coverage, either individually or through a company, at limits required by Section 61C-5, Florida
Administrative Code. I understand that any misstatement of facts in my application may invalidate it and subject me to
criminal penalties. I authorize the examination provider named herein to release information to the department for
verifying my successful completion of their examination.
Signature
Date
Please send your completed application, documentation and required $50 fee to:
Department of Business and Professional Regulation
Division of Hotels and Restaurants, Bureau of Elevator Safety
1940 North Monroe Street
Tallahassee, FL 32399-0783
Please use the entire 9-digit zip code in the address above to ensure proper handling.
www.MyFloridaLicense.com/dbpr/hr
2009 October 14
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