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Duplicate License Request DPBR 0090 - Florida

Duplicate License Request Form. This is a Florida form and can be used in Alcoholic Beverages And Tobacco Department Of Business And Professional Regulation Statewide .
 Fillable pdf Last Modified 3/18/2010
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DBPR 0090 ­ Duplicate License Request STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION LICENSEE INFORMATION License Number Licensee Name Social Security Number*/Federal Employer ID Number MAILING ADDRESS Street Address or P.O. Box City County (if Florida address) Country State Zip Code (+4 optional) I hereby certify that the license issued by the Florida Department of Business and Professional Regulation was (check one): Lost Stolen ­ no charge (requires police report) Destroyed *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, 654, and 666(a); and Sections 455.203(9), 409.2598, Florida Statutes. Social security numbers must be recorded on all professional and occupational license applications and will be used to allow efficient screening of applicants and licensees by Title IV-D Child Support Agency to assure compliance with child support obligations. I affirm that I have provided the above information completely and truthfully to the best of my knowledge. Licensee Sign Here: Date: FOR DIVISION USE ONLY Duplicate License Issued By: Date Issued: Fee for duplicate licenses $25, except: Boxing $15 Appraisers $20 Pari-Mutuel Wagering & Slots ­ No fee Condominium & Mobile Homes ­ No fee Yacht & Ship Brokers ­ No fee Hotels & Restaurants ­ No fee Elevators ­ No fee Labor Organizations ­ No fee American LegalNet, Inc. www.FormsWorkFlow.com
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