Notary

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Name

First Middle Last

Home Address

Street Address County City State ZIP Code

Place of Employment

Business Address

Street Address County City State ZIP Code

Mail to:

Home Address

Business Address

Other Address

Street Address City State ZIP Code

Home Phone

Business Phone

Sex

Male

Female

Race

Asian

Black of African American

Native American or Alaska Native

White

Other

Other Race

Florida Driver License (or other State of Florida Issued ID)

Date of Birth

MM slash DD slash YYYY

Social Security Number

Are you a legal resident of Florida?

Yes

Are you a United States Citizen?

Yes

Are you a wartime veteran with a disability rating of 50 percent or more?

Yes

Are you now or have you ever been commissioned a Notary Public in the State of Florida?

Yes

Commission expiration date

MM slash DD slash YYYY

Commission Number

Name for which your commission was issued

First Middle Last

Have you held any professional licenses or commissions (other than Notary Public) in Florida during the past 10 years?

Yes

Please list those positions

Have any of your past licenses been revoked?

Yes

(If Yes, you must submit a written statement about the nature of the action and any supporting documentation, such as a copy of the final order from the regulating agency.)

Have you been disciplined by a regulatory agency, including the Florida Bar, and including disciplinary action that is confidential?

Yes

(If Yes, you must submit a written statement about the nature of the action and any supporting documentation, such as a copy of the final order from the regulating agency.)

Have you been convicted of a felony or have you had an adjudication of guilt withheld for a felony offense?

Yes

(If Yes, you must submit a written statement of the nature of the offense(s), a copy of the court judgment and sentencing order. If convicted, you must submit a certificate of Restoration of Civil Rights.)

Are you currently on probation?

Yes

Affidavit of Character

State

County

Name of Affidavit

First Last

Name of Applicant

First Last

Address of Affidavit

Street Address County City State ZIP Code

Home Phone of Affidavit

Work Phone of Affidavit

Oath of Office

County of Applicant

Date

MM slash DD slash YYYY

Type Name of Applicant

Memorandum

Yes, I assert that identifying information provided in this application (other than my social security number, which I am aware is automatically exempt from public disclosure, pursuant to Fla. Stat. 119.071 should be excluded from inspection under Public Records Law

Yes

If Yes, please indicate which section of Florida Statutes provides this exemption from the Public Records Exemption Guide attached: https://dos.myflorida.com/media/695951/dos119.pdf *The attached DOS Public Records Exemption Request form is to act as a guide to assist applicants and does not have to be submitted if the "yes" box is not checked.

Florida Department of State Public Records Exemption Request

I attest that I am an individual covered under Section 119.071, F.S., as, check the appropriate item (only one):

current

former

I attest that I am an individual covered under Section 119.071, F.S., as, check the appropriate item (only one):

child of a current

child of a former

I attest that I am an individual covered under Section 119.071, F.S., as, check the appropriate item (only one):

spouse of a current

spouse of a former

and I hereby request the exemption (check applicable exemption category):

Addiction treatment facility, licensed pursuant to Chapter 397, F.S., directors, manager, supervisors, nurses, and clinical employees (s. 119.071(f)(d)2.s)

Child advocacy center, meeting the standards set forth in Chapter 39, F.S., directors, managers, supervisors, and clinical employees and members of a Child Protection Team as set forth in s. 39.303, F.S. (s. 119.071(4)(d)2.t)

Code Enforcement Officer (s. 119.071(4)(d)2.i)

County Tax Collector (s. 119.071(4)(d)2.n)

Dept. of Business and Professional Regulation-investigators and inspectors (s. 119.071(4)(d)2.m)

Dept. of Children and Family Services personnel whose duties involve investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities (s. 119.071(4)(d)2.a)

Dept. of Financial Services investigative personnel whose duties include the investigation of fraud, theft, workers’ compensation coverage requirements and compliance, other related criminal activities, or state regulatory requirement violations (s. 119.071(4)(d)2.b)

Dept. of Health personnel whose duties support the investigations of child abuse or neglect, determination of benefits, or the investigation, inspection, or prosecution of health care practitioners (s. 119.071(4)(d)2.a)

Dept. of Health personnel whose duties include, or result in, the determination or adjudication of eligibility for social security disability benefits, the investigation or prosecution of complaints filed against health care practitioners, or the inspection of health care practitioners or health care facilities licensed by the Department of Health (s. 119.071(4)(d)2.o)

Dept. of Revenue personnel or local government personnel whose duties relate to revenue collection and enforcement or child support enforcement. (s. 119.071(4)(d)2.a)

Domestic violence centers, certified under Chapter 39, F.S., staff and domestic violence advocates as defined in s. 90.5036(1)(b), F.S. (s. 119.071(4)(d)2.u)

Donor or prospective donor,* Cultural Endowment Program Trust Fund, Citizen Support Organizations or National, Historic Landmarks (publicly owned houses) (sections 265.605 and/or 267.17)

Emergency medical technicians or paramedics certified under Chapter 401, F.S (s. 119.071(4)(d)2.q)

Firefighter certified in compliance with s. 633.408, F.S. (s. 119.071(4)(d)2.d)

Guardian ad litem (s. 119.071(4)(d)2.j)

Human resource, labor relations, or employee relations director, assistant director, manager or assistant manager of any local government agency or water management district (s. 119.071(4)(d)2.h)

Impaired practitioner consultants whose duties result in a determination of a person’s skill and safety to practice a licensed profession (s. 119.071(4)(d)2.p)

Inspector general employees or internal audit department employees whose duties include auditing or investigating waste, fraud, abuse, theft, exploitation, or other activities that could lead to criminal prosecution or administrative discipline (s. 119.071(4)(d)2.r)

Judge - district court of appeal, circuit court and county court, or justice of the Florida Supreme Court (s. 119.071(4)(d)2.e)

Judicial or quasi-judicial officer (general and special magistrate, judge of compensation claims, administrative law judge of the Division of Administrative Hearings, and child support enforcement hearing officer) (s. 119.071(4)(d)2.g)

Juvenile probation officer, juvenile probation supervisor, detention superintendent, assistant detention superintendent, senior juvenile detention officer, juvenile detention officer supervisor, juvenile detention officer, house parent I and II, house parent supervisor, group treatment leader, group treatment leader supervisor, rehabilitation therapist, and social services counselor of the Dept. of Juvenile Justice (s. 119.071(4)(d)2.k)

Law enforcement personnel including correctional officers and correctional probation officers (s. 119.071(4)(d)2.a)

Office of Financial Regulation, Bureau of Financial Investigations, investigative personnel whose duties include the investigation of fraud, theft, other related criminal activities, or state regulatory requirement violations (s. 119.071(4)(d)2.c.)

Prosecutor (state attorney, assistant state attorney, statewide prosecutor, assistant statewide prosecutor) (s. 119.071(4)(d)2.f)

Public defenders and criminal conflict and civil regional counsel (includes assistant public defenders, assistant criminal conflict and assistant civil regional counsel) (s. 119.071(4)(d)2.l)

U.S. attorney or assistant attorney, U.S. appellate judge, U.S district court judge and U.S. magistrate (By signature below, person certifies that reasonable efforts made to protect information from being publicly accessible by other means) (S. 119.071(5)(i)

Victim* of sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery or domestic violence [Attach official verification that crime occurred. 5-year exemption. Contact Attorney General’s Office (850-414-3990) about eligibility for separate Address Confidentiality Program. See s. 741.465, Fla. Stat]

Other (list applicable statute):

Other Applicable Statute

Printed Name of Applicant

Date of Birth

MM slash DD slash YYYY

Phone

Address

Street Address City State ZIP Code

Notary

Affidavit of Character

Oath of Office

Memorandum

Florida Department of State Public Records Exemption Request

Company

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