State of Florida Department of Business and Professional Regulation Construction Industry Licensing Board Application for Certified Class-B Air Conditioning Contractor Who is Qualifying a Business Instructions
This form contains 440 fields organized into 73 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| ADDITIONAL CONTACT INFORMATION (OPTIONAL) | ||
| Alternate Phone Number | Text |
Please provide an alternate phone number for contact.
|
| Fax Number | Text |
Please provide your fax number.
|
| Alternate Email Address | Text |
Please provide an alternate email address for contact.
|
| Birth Date | ||
| Birth Date Day | Text |
Please enter the day of the birth date in DD format.
|
| Birth Date Month | Text |
Please enter the month of the birth date in MM format.
|
| Birth Date Year | Text |
Please enter the year of the birth date in YYYY format.
|
| Business Contact Information | ||
| Contact Name | Text |
Enter the full name of the business contact person. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Phone Number | Text |
Provide the phone number for the business contact. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Email Address | Text |
Enter the email address for the business contact. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Identification | ||
| Business Name | Text |
Please provide the legal name of the business to be qualified. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Doing Business As (DBA) | Text |
Please provide the name the business uses for public operations if it is different from its legal name. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Federal Employer ID Number (FEID) | Text |
Please provide the business's Federal Employer Identification Number. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Location Address | ||
| Business Location Street Address | Text |
Enter the street address for the business's physical location. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Location City | Text |
Enter the city for the business's physical location. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Location State | Text |
Enter the state for the business's physical location. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Location Zip Code | Text |
Enter the zip code for the business's physical location. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Location County | Text |
Enter the county for the business's physical location, if applicable. Fill only if 'Business Location State' is 'Florida'.
Depends on:
Business Location State
|
| Business Location Country | Text |
Enter the country for the business's physical location. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Qualification Status | ||
| Yes | Checkbox |
Check this box if the business is already qualified. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| No | Checkbox |
Check this box if the business is not yet qualified. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Business Type | ||
| Sole Proprietor | Checkbox |
Check this box if the business to be qualified is organized as a sole proprietorship. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| LLC | Checkbox |
Check this box if the business to be qualified is a limited liability company (LLC). Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Corporation | Checkbox |
Check this box if the business to be qualified is a corporation. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Partnership | Checkbox |
Check this box if the business to be qualified is a partnership. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Other Business Type | Text |
Provide the specific type of business if 'Other' was selected for the business type. Fill only if 'Other (please specify)' is 'Yes'.
Depends on:
Other (please specify)
|
| Other (please specify) | Checkbox |
Check this box if the business to be qualified is organized under a business type not listed above and specify that type. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Contact Information | ||
| Primary Email Address | Text |
Please provide your primary email address.
|
| Primary Phone Number | Text |
Please provide your primary phone number.
|
| Credit Score Verification | ||
| Credit Score 660 or Higher - Yes | Checkbox |
Check this box if the submitted credit report shows a credit score of 660 or higher.
|
| Credit Score 660 or Higher - No | Checkbox |
Check this box if the submitted credit report does not show a credit score of 660 or higher.
|
| Eighth Person Details | ||
| Eighth Person - Question 2 Yes | Checkbox |
Check this box if there are any pending bankruptcies or unsatisfied judgments or liens against the eighth person, a business they previously qualified, or the business they are applying to qualify.
|
| Eighth Person - Question 3 Yes | Checkbox |
Check this box if the eighth person has had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application in Florida or any other jurisdiction.
|
| Eighth Person - Question 4 Yes | Checkbox |
Check this box if the eighth person has had any license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or any other jurisdiction, or if any such proceeding or investigation is now pending.
|
| Eighth Person - Question 1 Yes | Checkbox |
Check this box if the eighth person has been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Authorized Representative Name | Text |
Enter the full printed name of the eighth person's authorized representative.
|
| Eighth Person - Question 1 No | Checkbox |
Check this box if the eighth person has not been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Eighth Person - Question 4 No | Checkbox |
Check this box if the eighth person has not had any license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or any other jurisdiction, and no such proceeding or investigation is now pending.
|
| Eighth Person - Question 2 No | Checkbox |
Check this box if there are no pending bankruptcies or unsatisfied judgments or liens against the eighth person, a business they previously qualified, or the business they are applying to qualify.
|
| Eighth Person - Question 3 No | Checkbox |
Check this box if the eighth person has not had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application in Florida or any other jurisdiction.
|
| Social Security Number | Text |
Enter the Social Security number for the eighth person.
|
| Employer Information | ||
| Employer Phone Number | Date |
Please provide the main phone number for the employer. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employer Name | Text |
Please enter the full legal name of the employer. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employer Email Address | Date |
Please provide the primary email address for the employer. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employment History | ||
| Employer Name | Text |
Enter the full legal name of the employer for this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employer City | Text |
Enter the city where the employer is located. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employer State and Zip Code | Text |
Enter the state and zip code of the employer's location. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Supervisor Phone Number | Text |
Enter the phone number of your supervisor. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Supervisor Name | Date |
Enter the full name of your immediate supervisor for this employment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Job Title | Date |
Enter your official job title during this period of employment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employment Start Year | Date |
Enter the year when this employment began. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employment End Year | Date |
Enter the year when this employment ended. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employment Start Month | Date |
Enter the month when this employment began. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Employment End Month | Date |
Enter the month when this employment ended. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| checkbox_329 | CheckBox | |
| checkbox_330 | CheckBox | |
| Experience Areas for Employment Period | ||
| Experience Area 1 | Text |
Enter the details for the first experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Experience Area 2 | Text |
Enter the details for the second experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Experience Area 3 | Text |
Enter the details for the third experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Experience Area 4 | Text |
Enter the details for the fourth experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| checkbox_180 | CheckBox | |
| checkbox_181 | CheckBox | |
| Fifth Business Owner | ||
| Fifth Owner Name | Text |
Please enter the full name of the fifth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fifth Owner Address | Text |
Please enter the full address for the fifth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fifth Owner SSN or FEID | Text |
Please enter the Social Security Number or Federal Employer Identification Number for the fifth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fifth Owner Percentage of Ownership | Number |
Please enter the percentage of ownership held by the fifth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fifth Person Details | ||
| Q3 Yes | Checkbox |
Check this box if the fifth person has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Q1 Yes | Checkbox |
Check this box if the fifth person has ever been convicted, found guilty, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Q2 Yes | Checkbox |
Check this box if the fifth person has any pending bankruptcies or unsatisfied judgments or liens against themselves or a business they qualified.
|
| Q4 Yes | Checkbox |
Check this box if the fifth person has ever had a license, registration, or permit disciplined (revoked, annulled, suspended, etc.), or if there is a pending proceeding or investigation related to such discipline.
|
| Fifth Person Authorized Representative Name | Text |
Enter the full printed name of the authorized representative for the fifth person.
|
| Q2 No | Checkbox |
Check this box if the fifth person does not have any pending bankruptcies or unsatisfied judgments or liens against themselves or a business they qualified.
|
| Q3 No | Checkbox |
Check this box if the fifth person has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Q1 No | Checkbox |
Check this box if the fifth person has never been convicted, found guilty, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Q4 No | Checkbox |
Check this box if the fifth person has never had a license, registration, or permit disciplined, and there is no pending proceeding or investigation related to such discipline.
|
| Fifth Person Social Security Number | Text |
Enter the Social Security Number for the fifth person.
|
| Financial Responsibility Course Completion | ||
| Yes | Checkbox |
Check this box if you have completed a financial responsibility course approved by the Construction Industry Licensing Board. Fill only if 'Credit Score 660 or Higher - No' is 'No'.
Depends on:
Credit Score 660 or Higher - No
|
| No | Checkbox |
Check this box if you have not completed a financial responsibility course approved by the Construction Industry Licensing Board. Fill only if 'Credit Score 660 or Higher - No' is 'No'.
Depends on:
Credit Score 660 or Higher - No
|
| Financial Responsibility Course Details | ||
| School Name | Text |
Please enter the name of the school where the financial responsibility course was completed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| School Provider Number | Number |
Please enter the provider number assigned to the school that offered the financial responsibility course. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Course Name | Text |
Please enter the full name of the financial responsibility course that was completed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Date(s) Attended | Date |
Please enter the date or dates when you attended the financial responsibility course. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Financial Responsibility of Proposed Business | ||
| Currently Has Approved FRO | Checkbox |
Check this box if your business currently has an approved Financially Responsible Officer. Fill only if 'Application Type' is 'Certified License and Qualify a Business'.
Depends on:
Certified License and Qualify a Business
|
| Approved Financially Responsible Officer Name and License Number | Text |
Please provide the name and license number of the currently approved Financially Responsible Officer. Fill only if 'Currently Has Approved FRO' is 'Yes'.
Depends on:
Currently Has Approved FRO
|
| Will Appoint FRO | Checkbox |
Check this box if your business intends to appoint a Financially Responsible Officer. Fill only if 'Application Type' is 'Certified License and Qualify a Business'.
Depends on:
Certified License and Qualify a Business
|
| Proposed Financially Responsible Officer Name | Text |
Please provide the name of the proposed Financially Responsible Officer who will be submitting the CILB 8 application. Fill only if 'Will Appoint FRO' is 'Yes'.
Depends on:
Will Appoint FRO
|
| Primary Qualifying Agent Assumes Responsibility | Checkbox |
Check this box if your business will not designate a Financially Responsible Officer, and the primary qualifying agent will assume financial responsibility. Fill only if 'Application Type' is 'Certified License and Qualify a Business'.
Depends on:
Certified License and Qualify a Business
|
| First Business Owner | ||
| Owner Name | Text |
Enter the full name of the first business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Owner Address | Text |
Enter the complete mailing address of the first business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Owner Social Security Number or FEID | Text |
Enter the Social Security Number (SSN) or Federal Employer Identification Number (FEID) of the first business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Owner Percentage of Ownership | Number |
Enter the percentage of ownership held by the first business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| First Explanation for Questions 1-2 | ||
| Person 1 | Checkbox |
Check this box if the explanation provided pertains to person number 1. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 2 | Checkbox |
Check this box if the explanation provided pertains to question number 2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 3 | Checkbox |
Check this box if the explanation provided pertains to person number 3. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 4 | Checkbox |
Check this box if the explanation provided pertains to person number 4. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 5 | Checkbox |
Check this box if the explanation provided pertains to person number 5. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 6 | Checkbox |
Check this box if the explanation provided pertains to person number 6. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 7 | Checkbox |
Check this box if the explanation provided pertains to person number 7. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 8 | Checkbox |
Check this box if the explanation provided pertains to question number 8. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Related Person Number | Number |
Enter the number of the person this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Subject | Text |
Provide a concise subject or title for this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Field 1 | Date |
Enter specific detail information relevant to this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Field 2 | Text |
Enter specific detail information relevant to this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Field 3 | Text |
Enter specific detail information relevant to this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Outcome Reference | Text |
Provide a reference or additional information regarding the outcome or decision of the explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Yes | Checkbox |
Check this box to indicate an affirmative choice regarding the explanation provided. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| No | Checkbox |
Check this box to indicate a negative choice regarding the explanation provided. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Full Explanation Description | Text |
Provide a detailed explanation for the 'Yes' answer to the questions. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Explanation for Questions 3-4 | ||
| Person 1 | Checkbox |
Check this box if this explanation relates to person number 1. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 2 | Checkbox |
Check this box if this explanation relates to person number 2. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 3 | Checkbox |
Check this box if this explanation relates to person number 3. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| First Explanation Related Person Number | Text |
Provide the primary number of the person associated with this explanation. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 4 | Checkbox |
Check this box if this explanation relates to person number 4. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 5 | Checkbox |
Check this box if this explanation relates to person number 5. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 6 | Checkbox |
Check this box if this explanation relates to person number 6. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Question 3 | Checkbox |
Check this box if this explanation relates to question number 3. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Question 4 | Checkbox |
Check this box if this explanation relates to question number 4. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| First Explanation Secondary Person Number | Text |
Provide an additional number of a person associated with this explanation. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| First Explanation Related Question Number | Text |
Provide the number of the specific question that this explanation addresses. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| First Explanation Details | Text |
Provide a detailed narrative explaining the 'Yes' answer for the person and question specified in this explanation block. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| First License Information | ||
| License State | Text |
Enter the state where the first business or professional license or registration was issued. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License From Year | Text |
Enter the year when the first business or professional license or registration became effective. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License Registration Type | Text |
Enter the type of the first business or professional license or registration. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License From Month | Text |
Enter the month when the first business or professional license or registration became effective. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License To Month | Text |
Enter the month when the first business or professional license or registration expired or was relinquished. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License To Day | Text |
Enter the day when the first business or professional license or registration expired or was relinquished. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License To Year | Text |
Enter the year when the first business or professional license or registration expired or was relinquished. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License From Day | Text |
Enter the day when the first business or professional license or registration became effective. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License Number | Text |
Enter the license number for the first business or professional license or registration. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| License Name Used | Text |
Enter the name under which the first business or professional license or registration was issued. Fill only if 'Held business or professional license/registration' is 'Yes'.
|
| First Offense Explanation | ||
| Person's Name | Text |
Enter the full name of the person to whom this explanation relates. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Offense | Text |
Describe the nature of the offense committed. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Trial | Checkbox |
Check this box if the penalty or disposition for the offense was a result of a trial. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Plea | Checkbox |
Check this box if the penalty or disposition for the offense was a result of a plea. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Yes | Checkbox |
Check this box if adjudication was withheld for the offense. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| No | Checkbox |
Check this box if adjudication was not withheld for the offense. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Date of Conviction/Plea | Date |
Provide the date of conviction, finding of guilt, or plea. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Date of Sentencing | Date |
Provide the date of sentencing. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| First Person Details | ||
| Question 3 Yes | Checkbox |
Check this box if the applicant has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Question 1 Yes | Checkbox |
Check this box if the applicant has ever been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Question 2 Yes | Checkbox |
Check this box if there are any pending bankruptcies, unsatisfied judgments, or liens against the applicant, a previously qualified business, or the business applying to qualify.
|
| Question 4 Yes | Checkbox |
Check this box if the applicant has ever had a license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or if such a proceeding or investigation is pending.
|
| Applicant Name | Text |
Please provide the full printed name of the first applicant.
|
| Question 4 No | Checkbox |
Check this box if the applicant has never had a license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and no such proceeding or investigation is pending.
|
| Question 1 No | Checkbox |
Check this box if the applicant has never been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Question 2 No | Checkbox |
Check this box if there are no pending bankruptcies, unsatisfied judgments, or liens against the applicant, a previously qualified business, or the business applying to qualify.
|
| Question 3 No | Checkbox |
Check this box if the applicant has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Social Security Number | Text |
Please enter the Social Security Number of the first applicant.
|
| First Prior Name | ||
| Prior Suffix | Text |
Please provide the prior name suffix used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Prior Last Name | Text |
Please provide the prior last name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Prior First Name | Text |
Please provide the prior first name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Prior Middle Name | Text |
Please provide the prior middle name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Prior Title | Text |
Please provide the prior title used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Qualifier Information | ||
| First Qualifier Name | Text |
Enter the name of the first qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Qualifier License Number | Text |
Enter the license number for the first qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Business Owner | ||
| Fourth Owner Name | Text |
Please provide the full name of the fourth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fourth Owner Address | Text |
Please provide the complete address of the fourth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fourth Owner SSN/FEID | Text |
Please provide the Social Security Number (SSN) or Federal Employer Identification Number (FEID) for the fourth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fourth Owner Ownership Percentage | Number |
Please provide the percentage of ownership held by the fourth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Fourth Person Details | ||
| Person 4, Question 4 Yes | Checkbox |
Check this box if the fourth person has ever had a license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or if any such proceeding or investigation is now pending.
|
| Person 4, Question 2 Yes | Checkbox |
Check this box if there are any pending bankruptcies, unsatisfied judgments, or liens against the fourth person or a business they previously qualified.
|
| Person 4, Question 1 Yes | Checkbox |
Check this box if the fourth person has ever been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Person 4, Question 3 Yes | Checkbox |
Check this box if the fourth person has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Fourth Person Authorized Representative Print Name | Text |
Enter the full printed name of the fourth authorized representative.
|
| Person 4, Question 1 No | Checkbox |
Check this box if the fourth person has never been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Person 4, Question 3 No | Checkbox |
Check this box if the fourth person has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Person 4, Question 4 No | Checkbox |
Check this box if the fourth person has never had a license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and no such proceeding or investigation is now pending.
|
| Person 4, Question 2 No | Checkbox |
Check this box if there are no pending bankruptcies, unsatisfied judgments, or liens against the fourth person or a business they previously qualified.
|
| Fourth Person Social Security Number | Text |
Enter the Social Security Number for the fourth person.
|
| Fourth Qualifier Information | ||
| Fourth Qualifier Name | Text |
Please enter the name of the fourth qualifier for the business. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Qualifier License Number | Text |
Please enter the license number for the fourth qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Full Legal Name | ||
| Suffix | Text |
Please provide your name suffix, such as Jr., Sr., or III.
|
| Title | Text |
Please provide your professional or courtesy title.
|
| Last Name | Text |
Please provide your legal last name.
|
| First Name | Text |
Please provide your legal first name.
|
| Middle Name | Text |
Please provide your legal middle name, if applicable.
|
| Gender | ||
| Female | Checkbox |
Check this box if the applicant's gender is female.
|
| Male | Checkbox |
Check this box if the applicant's gender is male.
|
| General | ||
| Mailing Street Address or P.O. Box | Text | |
| Mailing Address Line 2 | Text | |
| Residence Street Address | Text | |
| Residence Address Line 2 | Text | |
| Business Location Street Address | Text | |
| Business Location Address Line 2 | Text | |
| Job Details | ||
| Experience Area 2 | Text |
Provide the second experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Experience Area 3 | Text |
Provide the third experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Experience Area 1 | Text |
Provide the first experience area relevant to this employment period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Job Title and Duties | ||
| Job Title and Duties Description | Text |
Please provide a detailed description of your job title and duties on the job site(s) related to the categories mentioned above. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Job Title and Duties | Text |
Provide your job title and describe your duties on the job site(s) related to the categories listed above. Fill only if 'Heating and Cooling Systems', 'Heating Equipment', 'Air Conditioning Equipment', 'Ductwork' is 'Yes', any.
Depends on:
Heating and Cooling Systems, Heating Equipment, Air Conditioning Equipment, Ductwork
|
| Mailing Address | ||
| Street Address / P.O. Box | Text |
Enter the full street address or P.O. Box for the mailing address.
|
| City | Text |
Enter the city of the mailing address.
|
| State | Text |
Enter the state of the mailing address.
|
| Zip Code | Text |
Enter the zip code of the mailing address, including the optional 4-digit extension if applicable.
|
| Country | Text |
Enter the country of the mailing address.
|
| County (if Florida address) | Text |
Enter the county of the mailing address, if it is a Florida address. Fill only if 'State' is 'Florida'.
Depends on:
State
|
| Street Address or P.O. Box | Text |
Enter the street address or P.O. box for the mailing address. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| State | Text |
Enter the state for the mailing address. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Zip Code | Text |
Enter the zip code for the mailing address. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| City | Text |
Enter the city for the mailing address. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| County | Text |
Enter the county for the mailing address, especially if it is a Florida address. Fill only if 'State' is 'Florida'.
Depends on:
State
|
| Country | Text |
Enter the country for the mailing address. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Method of Qualification | ||
| Four Year Degree & Experience | Checkbox |
Check this box if you have a four-year construction-related degree from an accredited college (equivalent to three years experience) and one year of proven experience applicable to the category for which you are applying.
|
| Foreman Experience & College Credits (3+ years) | Checkbox |
Check this box if you have one year of experience as a foreman and not less than three years of credits from accredited college-level courses.
|
| Worker/Foreman Experience & College Credits (2 years) | Checkbox |
Check this box if you have one year of experience as a worker, one year of experience as a foreman, and two years of credits from accredited college-level courses.
|
| Worker/Foreman Experience & College Credits (1 year) | Checkbox |
Check this box if you have two years of experience as a worker, one year of experience as a foreman, and one year of credits from accredited college-level courses.
|
| Four Years Worker/Foreman Experience | Checkbox |
Check this box if you have four years of experience as a worker or foreman, of which at least one year must have been as a foreman.
|
| Upgrade Method | Checkbox |
Check this box if you are an air-conditioning Class C contractor holding an active current license for a minimum of one year in the classification in which you are certified, and meet the exemption requirements for the Employment History section.
|
| License Number | Text |
Please provide your license number for verification if you are qualifying using the 'Upgrade Method'. Fill only if 'Upgrade Method' is 'Yes'.
Depends on:
Upgrade Method
|
| Military Veteran Qualification | ||
| Three years military service & one year foreman experience | Checkbox |
Check this box if you have three years of military service and one year of experience as a foreman applicable to the category for which you are applying.
|
| Two years military service, one year foreman, one year worker/foreman | Checkbox |
Check this box if you have two years of military service, one year of experience as a foreman, and one year of experience as a worker or foreman applicable to the category for which you are applying.
|
| One year military service, one year foreman, two years worker/foreman | Checkbox |
Check this box if you have one year of military service, one year of experience as a foreman, and two years of experience as a worker or foreman applicable to the category for which you are applying.
|
| Ninth Person Details | ||
| Person 9 - Question 2 - Yes | Checkbox |
Check this box if Person #9 has any pending bankruptcies or unsatisfied judgments or liens against themself or a business they previously qualified or are applying to qualify.
|
| Person 9 - Question 3 - Yes | Checkbox |
Check this box if Person #9 has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Person 9 - Question 4 - Yes | Checkbox |
Check this box if Person #9 has ever had any license, registration, or permit disciplined (revoked, annulled, suspended, relinquished, surrendered) or if such a proceeding or investigation is now pending.
|
| Person 9 - Question 1 - Yes | Checkbox |
Check this box if Person #9 has ever been convicted, found guilty, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Ninth Person Authorized Representative Name | Text |
Please provide the full printed name of the ninth authorized representative.
|
| Person 9 - Question 3 - No | Checkbox |
Check this box if Person #9 has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Person 9 - Question 4 - No | Checkbox |
Check this box if Person #9 has never had any license, registration, or permit disciplined, and no such proceeding or investigation is now pending.
|
| Person 9 - Question 1 - No | Checkbox |
Check this box if Person #9 has never been convicted, found guilty, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Person 9 - Question 2 - No | Checkbox |
Check this box if Person #9 has no pending bankruptcies or unsatisfied judgments or liens against themself or a business they previously qualified or are applying to qualify.
|
| Ninth Person Social Security Number | Text |
Please provide the Social Security Number for the ninth person.
|
| Part A: Experience Areas | ||
| Part A - Installation of air conditioning and refrigeration equipment | Checkbox |
Check this box if your experience during this employment period included installation of air conditioning and refrigeration equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part A - Maintenance and servicing of air conditioning and refrigeration equipment | Checkbox |
Check this box if your experience during this employment period included maintenance and servicing of air conditioning and refrigeration equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part A - Sheet metal fabrication and ductwork | Checkbox |
Check this box if your experience during this employment period included fabrication and installation of sheet metal ductwork. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part A - Electrical power or wiring circuits for HVAC equipment | Checkbox |
Check this box if your experience during this employment period included electrical power or wiring circuits for HVAC equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part A: Experience Description | ||
| Experience Description | Text |
Please describe your areas of experience from this employment period that demonstrate substantial compliance with statutory experience requirements. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part A: Installation Experience | ||
| Installation Count | Text |
Please enter the number of installations you are reporting for this experience period. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating and Cooling Systems | Checkbox |
Check this box if you have experience with the installation of Heating and Cooling Systems for at least one year. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating Equipment | Checkbox |
Check this box if you have experience with the installation of Heating Equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Air Conditioning Equipment | Checkbox |
Check this box if you have experience with the installation of Air Conditioning Equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Ductwork | Checkbox |
Check this box if you have experience with the installation of Ductwork. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Installation Experience Description | Text |
Please provide a comprehensive description of your installation experience, detailing how it complies with statutory requirements. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating and Cooling Systems | Checkbox |
Check this box if your experience includes the installation of heating and cooling systems for at least one year. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Heating Equipment | Checkbox |
Check this box if your experience includes the installation of heating equipment. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Part A: Cooling Equipment | Checkbox |
Check this box if you have installation experience with cooling equipment during this employment period. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Part A: Refrigeration Systems | Checkbox |
Check this box if you have installation experience with refrigeration systems during this employment period. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Installation Experience Description | Text |
Provide a detailed description of your installation experience during this employment period that demonstrates compliance with statutory experience requirements. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Part B: Job Title and Duties | ||
| Job Title and Duties Description | Text |
Provide your job title and a detailed description of your duties performed on the job site(s) related to the listed categories. Fill only if 'Heating and Cooling Systems', 'Heating Equipment', 'Ductwork', 'Air Conditioning Equipment' is 'Yes' for any.
Depends on:
Heating and Cooling Systems, Heating Equipment, Ductwork, Air Conditioning Equipment
|
| Part B: Maintenance and Repair Categories | ||
| Heating and Cooling Systems | Checkbox |
Check this box if your experience includes the maintenance and repair of heating and cooling systems. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating Equipment | Checkbox |
Check this box if your experience includes the maintenance and repair of heating equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Ductwork | Checkbox |
Check this box if your experience includes the maintenance and repair of ductwork. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Air Conditioning Equipment | Checkbox |
Check this box if your experience includes the maintenance and repair of air conditioning equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Part B: Maintenance and Repair Experience | ||
| Maintenance and Repair Count | Number |
Enter the number of maintenance and repair experiences being reported. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating and Cooling Systems | Checkbox |
Check this box if your additional experience includes maintenance and repair of Heating and Cooling Systems. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating Equipment | Checkbox |
Check this box if your additional experience includes maintenance and repair of Heating Equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Air Conditioning Equipment | Checkbox |
Check this box if your additional experience includes maintenance and repair of Air Conditioning Equipment. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Ductwork | Checkbox |
Check this box if your additional experience includes maintenance and repair of Ductwork. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Heating and Cooling Systems | Checkbox |
Check this box if you have additional experience in the maintenance and repair of heating and cooling systems. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Heating Equipment | Checkbox |
Check this box if you have additional experience in the maintenance and repair of heating equipment. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Air Conditioning Equipment | Checkbox |
Check this box if you have additional experience in the maintenance and repair of air conditioning equipment. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Ductwork | Checkbox |
Check this box if you have additional experience in the maintenance and repair of ductwork. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Primary Qualifying Agent | ||
| License Number | Text |
Please enter the license number for the primary qualifying agent, if applicable. Fill only if 'Application Type' is 'Certified License and Qualify a Business'.
Depends on:
Certified License and Qualify a Business
|
| Primary Qualifying Agent Name | Text |
Please provide the full name of the primary qualifying agent. Fill only if 'Application Type' is 'Certified License and Qualify a Business'.
Depends on:
Certified License and Qualify a Business
|
| Prior Name Usage Confirmation | ||
| No | Checkbox |
Check this box if you have not used, been known as, or are not currently known by another name other than the name signed to the application.
|
| Yes | Checkbox |
Check this box if you have used, been known as, or are currently known by another name (e.g., maiden name, pseudonym, nickname) other than the name signed to the application.
|
| Qualification Details | ||
| License Type | Text |
Enter the type or name of the certified license or qualification. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Qualification Description | Text |
Provide a detailed description of your qualification or experience, including relevant responsibilities and achievements. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| License Number | Text |
Enter the identification number for the certified license. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Employment Start Date | Date |
Provide the date when your employment or experience period began. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Company Name | Text |
Enter the name of the company or organization where this qualification or experience was gained. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Employment End Date | Date |
Provide the date when your employment or experience period ended, or indicate 'Present' if still employed. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Total Experience Months | Text |
Enter the total number of months of experience relevant to this qualification, in addition to the years. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Specific Experience Months | Text |
Enter the number of months for a specific type of experience required for this qualification, in addition to the years. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Total Experience Years | Text |
Enter the total number of years of experience relevant to this qualification. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| Specific Experience Years | Text |
Enter the number of years for a specific type of experience required for this qualification. Fill only if 'Qualification Method' is not 'Upgrade Method'.
Depends on:
Upgrade Method
|
| checkbox_139 | CheckBox | |
| checkbox_140 | CheckBox | |
| Residence Address | ||
| Residence Street Address | Text |
Enter the street address for the residence.
|
| Residence City | Text |
Enter the city of the residence address.
|
| Residence State | Text |
Enter the state of the residence address.
|
| Residence Zip Code | Text |
Enter the postal zip code of the residence address.
|
| Residence Country | Text |
Enter the country of the residence address.
|
| Residence County (if Florida address) | Text |
Enter the county of the residence address, if applicable for a Florida address. Fill only if 'Residence State' is 'Florida'.
Depends on:
Residence State
|
| Second Business Owner | ||
| Owner Name | Text |
Please enter the full legal name of the second business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Owner Address | Text |
Please provide the complete mailing address for the second business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Owner SSN/FEID | Text |
Please enter the Social Security Number or Federal Employee Identification Number for the second business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Ownership Percentage | Number |
Please enter the percentage of ownership held by the second business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Second Explanation for Questions 1-2 | ||
| Person 1 | Checkbox |
Check this box if the explanation being provided relates to person #1. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 2 | Checkbox |
Check this box if the explanation being provided relates to person #2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 3 | Checkbox |
Check this box if the explanation being provided relates to question #3. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Related Person Number | Text |
Enter the number of the person this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 4 | Checkbox |
Check this box if the explanation being provided relates to person #4. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 5 | Checkbox |
Check this box if the explanation being provided relates to person #5. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 6 | Checkbox |
Check this box if the explanation being provided relates to person #6. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 7 | Checkbox |
Check this box if the explanation being provided relates to question #7. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 8 | Checkbox |
Check this box if the explanation being provided relates to person #8. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail First Line | Text |
Provide the first line of the detailed explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Second Line Part 1 | Date |
Provide the first part of the second line of the detailed explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Second Line Part 2 | Text |
Provide the second part of the second line of the detailed explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Related Question Number | Text |
Enter the number of the question this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Detail Third Line | Text |
Provide the third line of the detailed explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Yes | Checkbox |
Check this box to indicate an affirmative response for this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| No | Checkbox |
Check this box to indicate a negative response for this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Description Details | Text |
Provide a detailed description for this explanation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Explanation for Questions 3-4 | ||
| Person 1 | Checkbox |
Check this box if this explanation relates to person number 1. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Question 2 | Checkbox |
Check this box if this explanation relates to question number 2. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Related Person Number | Text |
Enter the numerical ID of the person for whom this explanation of a 'Yes' answer is provided. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 3 | Checkbox |
Check this box if this explanation relates to person number 3. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 4 | Checkbox |
Check this box if this explanation relates to person number 4. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Question 5 | Checkbox |
Check this box if this explanation relates to question number 5. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 6 | Checkbox |
Check this box if this explanation relates to person number 6. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 7 | Checkbox |
Check this box if this explanation relates to person number 7. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Person 8 | Checkbox |
Check this box if this explanation relates to person number 8. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Additional Related Person Number | Text |
Enter the numerical ID of an additional person for whom this explanation of a 'Yes' answer is provided, if applicable. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Related Question Number | Text |
Enter the number of the question (either 3 or 4) to which this explanation of a 'Yes' answer corresponds. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Explanation Description | Text |
Provide a detailed textual explanation elaborating on the 'Yes' answer given to the specified question and person. Fill only if 'any of questions 3-4' is 'Yes'.
Depends on:
Question 3 Yes, Question 4 Yes, Question 3 Yes (Person 2), Question 4 Yes (Person 2), Person 3 - Question 3: Yes, Person 3 - Question 4: Yes, Person 4, Question 3 Yes, Person 4, Question 4 Yes, Q3 Yes, Q4 Yes, Question 3 Yes, Question 4 Yes, Seventh Person - Question 3 Yes, Seventh Person - Question 4 Yes, Eighth Person - Question 3 Yes, Eighth Person - Question 4 Yes, Person 9 - Question 3 - Yes, Person 9 - Question 4 - Yes, Tenth Person - Question 3 - Yes, Tenth Person - Question 4 - Yes
|
| Second License Information | ||
| Second License Type | Text |
Please enter the type of your second business or professional license or registration. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License State | Text |
Please enter the state where your second license or registration was issued. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License From Month | Text |
Please enter the month when your second license or registration became effective. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License From Day | Text |
Please enter the day when your second license or registration became effective. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License To Month | Text |
Please enter the month when your second license or registration expired or will expire. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License To Day | Text |
Please enter the day when your second license or registration expired or will expire. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License To Year | Number |
Please enter the year when your second license or registration expired or will expire. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License From Year | Number |
Please enter the year when your second license or registration became effective. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License Number | Text |
Please enter the license number for your second business or professional license or registration. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second License Name Used | Text |
Please enter the name used on your second business or professional license or registration. Fill only if 'License Registration Type' is filled.
Depends on:
License Registration Type
|
| Second Offense Explanation | ||
| Name of Person | Text |
Enter the name of the person to whom this explanation relates. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Offense | Text |
Enter the specific offense being explained. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Trial | Checkbox |
Check this box if the penalty or disposition was a result of a trial. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Plea | Checkbox |
Check this box if the penalty or disposition was a result of a plea. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Adjudication Withheld - No | Checkbox |
Check this box if adjudication was not withheld for the offense. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Adjudication Withheld - Yes | Checkbox |
Check this box if adjudication was withheld for the offense. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Date of Conviction/Plea | Date |
Enter the date of conviction, finding of guilt, or plea. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Date of Sentencing | Date |
Enter the date the sentencing occurred. Fill only if 'Background Questions 1 or 2' is 'Yes'
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Second Person Details | ||
| Question 3 Yes (Person 2) | Checkbox |
Check this box if the second person has ever had an application for registration, certification, or licensure in Florida or any other jurisdiction denied, or if there is a pending proceeding or investigation to deny such an application. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 1 Yes (Person 2) | Checkbox |
Check this box if the second person has ever been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 4 Yes (Person 2) | Checkbox |
Check this box if the second person has ever had any license, registration, or permit to practice a regulated profession, occupation, vocation, or business revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or any other jurisdiction, or if any such proceeding or investigation is now pending. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 2 Yes (Person 2) | Checkbox |
Check this box if there are any pending bankruptcies or unsatisfied judgments or liens against the second person, a business they previously qualified, or a business they are applying to qualify. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Second Person Authorized Representative Name | Text |
Enter the printed full name of the second authorized representative. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 4 No (Person 2) | Checkbox |
Check this box if the second person has never had any license, registration, or permit to practice a regulated profession, occupation, vocation, or business revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or any other jurisdiction, and no such proceeding or investigation is now pending. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 1 No (Person 2) | Checkbox |
Check this box if the second person has never been convicted, found guilty of, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 2 No (Person 2) | Checkbox |
Check this box if there are no pending bankruptcies or unsatisfied judgments or liens against the second person, a business they previously qualified, or a business they are applying to qualify. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Question 3 No (Person 2) | Checkbox |
Check this box if the second person has never had an application for registration, certification, or licensure in Florida or any other jurisdiction denied, and there is no pending proceeding or investigation to deny such an application. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Second Person Social Security Number | Text |
Enter the Social Security Number for the second person. Fill only if 'Secondary Qualifying Agent Name' is filled.
Depends on:
Secondary Qualifying Agent Name
|
| Second Prior Name | ||
| Second Prior Middle Name | Text |
Enter the middle name for the second prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Prior Name Suffix | Text |
Enter the suffix for the second prior name used, such as Jr., Sr., or III. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Prior Last Name | Text |
Enter the last name for the second prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Prior First Name | Text |
Enter the first name for the second prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Prior Name Title | Text |
Enter the title for the second prior name used, such as Mr., Ms., or Dr. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Qualifier Information | ||
| Second Qualifier Name | Text |
Please provide the full name of the second qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Qualifier License Number | Text |
Please provide the license number for the second qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Section I – Application Type | ||
| Certified License and Qualify a Business | Checkbox |
Check this box if you are applying for a certified license and will be qualifying a single business entity.
|
| Section VI – Secondary Qualifier Information (Optional) | ||
| Secondary Qualifying Agent Name | Text |
Please enter the full name of the secondary qualifying agent.
|
| Secondary Qualifier License Number | Text |
Please provide the license number for the secondary qualifying agent, if applicable.
|
| Section VIII –Insurance Coverage | ||
| Public Liability and Property Damage Insurance Yes | Checkbox |
Check this box if you have obtained public liability and property damage insurance in the amounts determined by the Construction Industry Licensing Board, as specified in this section.
|
| Public Liability and Property Damage Insurance No | Checkbox |
Check this box if you have not obtained public liability and property damage insurance in the amounts determined by the Construction Industry Licensing Board, as specified in this section.
|
| Workers' Compensation Insurance Yes | Checkbox |
Check this box if you have obtained workers' compensation insurance or filed for an exemption with the Division of Workers' Compensation.
|
| Workers' Compensation Insurance No | Checkbox |
Check this box if you have not obtained workers' compensation insurance or filed for an exemption, but attest that you will obtain an exemption within 30 days after your license is issued.
|
| Section XIII – Affirmation by Written Declaration | ||
| Declaration Date | Date |
Provide the date the declaration is signed.
|
| Printed Name | Text |
Provide the printed full name of the individual making the declaration.
|
| Seventh Business Owner | ||
| Seventh Business Owner Name | Text |
Provide the full name of the seventh business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Seventh Business Owner Address | Text |
Enter the complete mailing address for the seventh business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Seventh Business Owner SSN or FEID | Text |
Enter the Social Security Number (SSN) or Federal Employer Identification Number (FEID) for the seventh business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Seventh Business Owner Percentage of Ownership | Number |
Specify the percentage of ownership held by the seventh business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Seventh Person Details | ||
| Seventh Person - Question 4 Yes | Checkbox |
Check this box if the seventh person has ever had any license, registration, or permit to practice a regulated profession revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or if any such proceeding or investigation is now pending.
|
| Seventh Person - Question 3 Yes | Checkbox |
Check this box if the seventh person has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Seventh Person - Question 1 Yes | Checkbox |
Check this box if the seventh person has ever been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Seventh Person - Question 2 Yes | Checkbox |
Check this box if there are any pending bankruptcies or unsatisfied judgments or liens against the seventh person or a business they previously qualified.
|
| Seventh Person Authorized Representative Print Name | Text |
Please enter the full printed name of the seventh authorized representative.
|
| Seventh Person - Question 1 No | Checkbox |
Check this box if the seventh person has never been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Seventh Person - Question 2 No | Checkbox |
Check this box if there are no pending bankruptcies or unsatisfied judgments or liens against the seventh person or a business they previously qualified.
|
| Seventh Person - Question 3 No | Checkbox |
Check this box if the seventh person has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Seventh Person - Question 4 No | Checkbox |
Check this box if the seventh person has never had any license, registration, or permit to practice a regulated profession revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and no such proceeding or investigation is now pending.
|
| Seventh Person Social Security Number | Text |
Please provide the Social Security Number for the seventh person.
|
| Sixth Business Owner | ||
| Sixth Owner Name | Text |
Enter the full name of the sixth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Sixth Owner Address | Text |
Enter the full address of the sixth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Sixth Owner Social Security Number or FEID | Text |
Enter the Social Security Number (SSN) or Federal Employer Identification Number (FEID) for the sixth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Sixth Owner Percentage of Ownership | Number |
Enter the percentage of ownership held by the sixth business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Sixth Person Details | ||
| Question 3 Yes | Checkbox |
Check this box if the sixth person has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Question 1 Yes | Checkbox |
Check this box if the sixth person has ever been convicted or found guilty of a crime, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Question 4 Yes | Checkbox |
Check this box if the sixth person has ever had any license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or if any such proceeding or investigation is now pending.
|
| Question 2 Yes | Checkbox |
Check this box if there are any pending bankruptcies or unsatisfied judgments or liens against the sixth person, a business they previously qualified, or the business they are applying to qualify.
|
| Sixth Person Authorized Representative Print Name | Text |
Please provide the full printed name of the sixth authorized representative.
|
| Question 1 No | Checkbox |
Check this box if the sixth person has never been convicted or found guilty of a crime, or entered a plea of guilty or nolo contendere to a crime in any jurisdiction.
|
| Question 4 No | Checkbox |
Check this box if the sixth person has never had any license, registration, or permit revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and no such proceeding or investigation is now pending.
|
| Question 2 No | Checkbox |
Check this box if there are no pending bankruptcies or unsatisfied judgments or liens against the sixth person, a business they previously qualified, or the business they are applying to qualify.
|
| Question 3 No | Checkbox |
Check this box if the sixth person has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Sixth Person Social Security Number | Text |
Please provide the social security number for the sixth person.
|
| Social Security Number | ||
| Social Security Number | Text |
Please provide your Social Security Number.
|
| Tenth Person Details | ||
| Tenth Person - Question 2 - Yes | Checkbox |
Check this box if the tenth person has any pending bankruptcies or unsatisfied judgments or liens against themselves or a business they previously qualified, or the business they are applying to qualify.
|
| Tenth Person - Question 3 - Yes | Checkbox |
Check this box if the tenth person has ever had an application for registration, certification, or licensure denied, or has a pending proceeding or investigation to deny such an application.
|
| Tenth Person - Question 4 - Yes | Checkbox |
Check this box if the tenth person has ever had any license, registration, or permit to practice a regulated profession, occupation, vocation, or business revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or has any such proceeding or investigation pending.
|
| Tenth Person - Question 1 - Yes | Checkbox |
Check this box if the tenth person has ever been convicted, found guilty, or entered a plea of guilty/nolo contendere to a crime in any jurisdiction.
|
| Tenth Person Authorized Representative Print Name | Text |
Please provide the full printed name of the authorized representative for the tenth person.
|
| Tenth Person - Question 1 - No | Checkbox |
Check this box if the tenth person has never been convicted, found guilty, or entered a plea of guilty/nolo contendere to a crime in any jurisdiction.
|
| Tenth Person - Question 2 - No | Checkbox |
Check this box if the tenth person does not have any pending bankruptcies or unsatisfied judgments or liens against themselves or a business they previously qualified, or the business they are applying to qualify.
|
| Tenth Person - Question 4 - No | Checkbox |
Check this box if the tenth person has never had any license, registration, or permit to practice a regulated profession, occupation, vocation, or business revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and does not have any such proceeding or investigation pending.
|
| Tenth Person - Question 3 - No | Checkbox |
Check this box if the tenth person has never had an application for registration, certification, or licensure denied, and does not have a pending proceeding or investigation to deny such an application.
|
| Tenth Person Social Security Number | Text |
Please provide the social security number for the tenth person.
|
| Third Business Owner | ||
| Third Owner Name | Text |
Enter the full name of the third business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Third Owner Address | Text |
Enter the complete street address of the third business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Third Owner SSN or FEID | Text |
Enter the Social Security Number (SSN) or Federal Employer Identification Number (FEID) for the third business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Third Owner Ownership Percentage | Number |
Enter the percentage of ownership held by the third business owner. Fill only if 'Certified License and Qualify a Business' is 'Yes'.
Depends on:
Certified License and Qualify a Business
|
| Third Explanation for Questions 1-2 | ||
| Person Number 1 | Text |
Enter the first person number this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 1 | Checkbox |
Check this box if this explanation relates to person #1. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 2 | Checkbox |
Check this box if this explanation relates to person #2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 3 | Checkbox |
Check this box if this explanation relates to person #3. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 4 | Checkbox |
Check this box if this explanation relates to person #4. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 5 | Checkbox |
Check this box if this explanation relates to person #5. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person 6 | Checkbox |
Check this box if this explanation relates to person #6. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 1 | Checkbox |
Check this box if this explanation relates to Question 1. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question 2 | Checkbox |
Check this box if this explanation relates to Question 2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person Number 2 | Text |
Enter the second person number this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Person Number 3 | Text |
Enter the third person number this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question Number 1 | Text |
Enter the first question number this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Question Number 2 | Text |
Enter the second question number this explanation relates to. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Further Related Number | Text |
Enter any additional person or question number, or other related reference number, relevant to this explanation. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| No | Checkbox |
Check this box if the explanation provided clarifies a 'No' answer or negates a 'Yes' answer to Question 1 or Question 2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Yes | Checkbox |
Check this box if the explanation provided affirms a 'Yes' answer to Question 1 or Question 2. Fill only if 'any of questions 1-2' is 'Yes'.
Depends on:
Question 1 Yes, Question 2 Yes, Question 1 Yes (Person 2), Question 2 Yes (Person 2), Person 3 - Question 1: Yes, Person 3 - Question 2: Yes, Person 4, Question 1 Yes, Person 4, Question 2 Yes, Q1 Yes, Q2 Yes, Question 1 Yes, Question 2 Yes, Seventh Person - Question 1 Yes, Seventh Person - Question 2 Yes, Eighth Person - Question 1 Yes, Eighth Person - Question 2 Yes, Person 9 - Question 1 - Yes, Person 9 - Question 2 - Yes, Tenth Person - Question 1 - Yes, Tenth Person - Question 2 - Yes
|
| Explanation Description | Text |
Provide a detailed explanation regarding the 'Yes' answers to the questions for the specified persons. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third License Information | ||
| Third License Type | Text |
Please provide the type of the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License State | Text |
Please provide the state where the third license or registration was issued. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License From Month | Text |
Please provide the starting month for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License From Day | Text |
Please provide the starting day for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License To Month | Text |
Please provide the ending month for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License To Day | Text |
Please provide the ending day for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License To Year | Text |
Please provide the ending year for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License From Year | Text |
Please provide the starting year for the third license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License Number | Text |
Please provide the license number for the third listed license or registration. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third License Name Used | Text |
Please provide the name used when the third license or registration was active. Fill only if 'Second License Type' is filled.
Depends on:
Second License Type
|
| Third Person Details | ||
| Person 3 - Question 1: Yes | Checkbox |
Check this box if Person #3 has ever been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Person 3 - Question 2: Yes | Checkbox |
Check this box if Person #3 has any pending bankruptcies or unsatisfied judgments or liens against themselves, a business they previously qualified, or the business they are applying to qualify.
|
| Person 3 - Question 3: Yes | Checkbox |
Check this box if Person #3 has ever had an application for registration, certification, or licensure denied, or if there is a pending proceeding or investigation to deny such an application.
|
| Person 3 - Question 4: Yes | Checkbox |
Check this box if Person #3 has ever had any license, registration, or permit to practice a regulated profession revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, or if any such proceeding or investigation is now pending.
|
| Third Person Social Security Number | Text |
Please enter the Social Security Number for the third person.
|
| Person 3 - Question 4: No | Checkbox |
Check this box if Person #3 has never had any license, registration, or permit to practice a regulated profession revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined, and no such proceeding or investigation is now pending.
|
| Person 3 - Question 3: No | Checkbox |
Check this box if Person #3 has never had an application for registration, certification, or licensure denied, and there is no pending proceeding or investigation to deny such an application.
|
| Person 3 - Question 1: No | Checkbox |
Check this box if Person #3 has never been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, a crime in any jurisdiction.
|
| Person 3 - Question 2: No | Checkbox |
Check this box if Person #3 does not have any pending bankruptcies or unsatisfied judgments or liens against themselves, a business they previously qualified, or the business they are applying to qualify.
|
| Third Person Authorized Representative Print Name | Text |
Please enter the full printed name of the third person's authorized representative.
|
| Third Prior Name | ||
| Third Prior Middle Name | Text |
Please enter the middle name of the third prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Prior Last Name | Text |
Please enter the last name of the third prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Prior First Name | Text |
Please enter the first name of the third prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Prior Title | Text |
Please enter any title associated with the third prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Prior Suffix | Text |
Please enter any suffix associated with the third prior name used. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Qualifier Information | ||
| Third Qualifier Name | Text |
Please provide the name of the third qualifier for the business. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Qualifier License Number | Text |
Please provide the license number for the third qualifier. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Total Experience Time | ||
| Worker Experience Years | Number |
Enter the total number of years of experience as a worker from your employment history. Fill only if 'Worker' is 'Yes'.
Depends on:
Worker
|
| Foreman Experience Years | Number |
Enter the total number of years of experience as a foreman from your employment history. Fill only if 'Foreman' is 'Yes'.
Depends on:
Foreman
|
| Worker | Checkbox |
Check this box if you are providing your total time of experience as a worker. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|
| Foreman | Checkbox |
Check this box if you are providing your total time of experience as a foreman. Fill only if 'Upgrade Method' is 'No'.
Depends on:
Upgrade Method
|