business license research & compliance package sample · goss development company prepared by:...

Prepared for:GOSS DEVELOPMENTCOMPANY

Prepared by:Corporation Service Company

Prepared on:March 10, 2010

Business License Research & Compliance Package

Business License Portfolio Management | Business License Filing & Renewal Services

License Verification | Audit & Gap Analysis | Fully-Managed Outsourcing

Sample


Principal Business Address Contact Information2000 Beachside Drive RYAN PETERVero Beach,FL,32063 GOSS DEVELOPMENT COMPANYCounty:

[email protected]

Your RequestBLCP

Location(s) Where You Conduct Business Products/Services ProvidedFL,Vero Beach Estate Homes

Business Activity/Industry Segment Order IDResidential Construction 305703 - 5

Number of Employees1

This report contains business license and tax application(s) that have been identified on your behalf.Each application is preceded with a cover sheet containing the licensing authority's contact information (name,address, telephone number, etc.) as well as instructions on how to file your application.

State Level (FL):- Application for Initial Issuance of Licensure for Certified Contractors- Application to Collect And/Or Report Tax

Local Level (Vero Beach)- Business Tax Registration

Samp

le


Package ScopeThis report sets forth the license and permit requirements we have identified as being relevant to ResidentialConstruction. These requirements are based on details provided in connection with location and business activity.The business address provided is within the incorporated city of Vero Beach, County of in the State of FL.

Overview of Licenses and Permits

Federal Level:

State Level (FL):The following license and/or permit requirements may be relevant to Residential Construction at the State level:- Application for Initial Issuance of Licensure for Certified Contractors- Application to Collect And/Or Report Tax

County Level ()We have not identified any license and/or permit requirements that are relevant to Residential Construction at theCounty level.

Local Level (Vero Beach)The following license and/or permit requirements may be relevant to Residential Construction at the Local level:- Business Tax Registration

If you are interested in having CSC assist you with form preparation, filing or any of the services listed below, pleasecontact a CSC Business License Specialist at (800)-927-9801 x5077 or email [email protected].

- Business License Prep & Filing - Fictitious Name (DBA) - License Outsourcing Services- Business License Renewal Service - License Portfolio Management - Inc & LLC Formations- Federal Tax Identification (EIN) - Audit & Gap Analysis - Qualifications- License Verification

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If you have questions regarding this application, pleasecontact the issuing authority using the informationprovided below.

Issuing Office

Mailing AddressMail the application to the mailing address providedbelow, unless otherwise noted on the form.

General Notes

Information pertaining to this form

Application for Initial Issuance ofLicensure for Certified Contractors(State, FL)

Sample

INFORMATION REGARDING COMPLETION OF INITIAL ISSUANCE OF LICENSURE FOR CERTIFIED CONTRACTORS

DBPR CILB 4359 Application begins on page 5.

If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395. In filing an application, be certain that the application is completely filled out, that all questions are answered truthfully and that all the information requested is provided. Please type or print in ink. Applicants are cautioned to read questions thoroughly. A false answer concerning financial or background information will subject the applicant to denial or subsequent disciplinary action against the license. QUALIFICATIONS: In order to become a licensed certified contractor in the State of Florida, an applicant must meet educational requirements, pass the state certification examination, obtain workers’ compensation and general liability insurance coverage, and demonstrate financial responsibility. A “certified contractor” means any contractor who possesses a certificate of competency issued by the department and who shall be allowed to contract in any jurisdiction in the state without being required to fulfill the competency requirements of that jurisdiction. Please note that if you currently hold a license and you intend to operate the proposed license under a separate business organization, you must also complete the Qualifying Additional Business Organization Application Package. This applies even if you intend to qualify a business organization with one license and operate as an individual with the other license. This applies even if one business is operating under a Division I license and the other is operating under a Division II license. However, you do not have to pay the fee listed in the Qualifying Additional Business Organization Application. ELECTRONIC FINGERPRINTING: Beginning November 1, 2007, all applications for initial licensure or changes of status will be required to have a criminal background check performed by the Florida Department of Law Enforcement and Federal Bureau of Investigation. You are responsible for ensuring that your fingerprints have been scanned by the Department’s vendor, Pearson VUE, prior to submitting your application. The fingerprint results are only valid for a period of six months from the date you submitted the fingerprints to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. Electronic fingerprinting is located at various convenient sites throughout Florida (https://www.myfloridalicense.com/efp3.html). Reservations and payment can be made by visiting the Pearson VUE reservation website at www.PearsonVUE.com (and selecting ‘Digital Fingerprinting Services’) or by calling Pearson VUE at 1.877.238.8232. You must pay a fee of $57.25 to Pearson VUE for the processing of your electronic fingerprints. This cost is in addition to the application fees listed on this application package. If you are located outside of the state of Florida, or if you have any questions regarding the electronic fingerprinting process, please visit http://www.myflorida.com/dbpr/pro/cilb/faq.html. COMPUTER-BASED BUSINESS AND FINANCE EXAMINATION/FEE CHANGE: As of January 1, 2009, the business and finance portion of the state certification examination will be computer-based. As a result, the department now collects the examination administration fee at the time of examination. Please refer to the instructions on page 2 for the revised initial licensure fee schedule.

2009 October Page 1 of 20 CILB: Initial Licensure Certified Contractor

Sample

https://www.myfloridalicense.com/efp3.html

http://www.pearsonvue.com/

http://www.myflorida.com/dbpr/pro/cilb/faq.html

APPLICATION CHECKLIST: Select the appropriate “Transaction” below which applies to your situation and follow the steps identified in the corresponding “Application Checklist” box.

TRANSACTION APPLICATION CHECKLIST

Initial Issuance of Licensure for CERTIFIED Contractors FOR INDIVIDUAL ONLY

Make check payable to the Department of Business and Professional Regulation.

FEES: IF ALL EXAM PARTS WERE PASSED PRIOR TO JANUARY 1, 2009:

Applying for initial licensure from MAY 1st of an EVEN YEAR through AUGUST 31st of an ODD YEAR – $409

OR Applying for initial licensure from SEPTEMBER 1st of an ODD YEAR

through APRIL 30th of an EVEN YEAR – $309 IF ANY EXAM PART WAS PASSED AFTER JANUARY 1, 2009:



through APRIL 30th of an EVEN YEAR – $149 FORMS:

DBPR CILB 4359 – Initial Issuance of Licensure for Certified Contractors and have work experience affidavit notarized.

DBPR 0010 – Master Individual Application DBPR CILB 4370 – CILB Financial Statement (For active status

only.) DBPR 0050 and DBPR 0060, as applicable, if you responded “yes”

to any of the Financial Responsibility Questions or any questions on DBPR 0010 – Master Individual Application. Be advised that affirmative responses may require that your application be presented to the Construction Industry Licensing Board for review.

SUPPORTING DOCUMENTATION:

Credit report on applicant from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state and federal levels. Not every credit reporting agency includes this information. For a list of agencies, visit www.myflorida.com/dbpr/pro/cilb/index.html. (For active status only.)

Make sure you have filed your electronic fingerprints with Pearson VUE. Please note that the fingerprint results are only valid for a period of six months from the date the fingerprints were submitted to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. (See page 1 of this package for additional information.)

Proof of satisfaction of liens, judgments and discharge of bankruptcy, if applicable. (For active status only.)

Bank verification letter. (Required if you include cash on your financial statement – for active status only.)

Listing of machinery and equipment. (For active status only.) Proof of CILB grade report indicating overall status as “passed” for all

applicable parts of examination. Grade report must be no older than three years.

Swimming Pool Specialty License applicants - provide practical examiner grade report and CILB-approved education provider certificates indicating completion of one hour each of workplace safety, business practices and workers’ compensation courses.


Sample

http://www.myflorida.com/dbpr/pro/cilb/index.html


Initial Issuance of Licensure for CERTIFIED Contractor WHO IS QUALIFYING A BUSINESS (ACTIVE STATUS ONLY.)

Make check payable to the Department of Business and Professional Regulation.

FEES: IF ALL EXAM PARTS WERE PASSED PRIOR TO JANUARY 1, 2009:



through APRIL 30th of an EVEN YEAR – $309 IF ANY EXAM PART WAS PASSED AFTER JANUARY 1, 2009:



through APRIL 30th of an EVEN YEAR – $149 FORMS:

DBPR CILB 4359 – Initial Issuance of Licensure for Certified Contractors and have work experience affidavit notarized.

DBPR 0010 – Master Individual Application DBPR CILB 4370 – CILB Financial Statement on BUSINESS DBPR CILB 4357 – Construction Business Information Form DBPR 0050 and DBPR 0060, as applicable, if you responded “yes”

to any of the Financial Responsibility Questions on DBPR 0010 – Master Individual Application or DBPR CILB 4357 – Construction Business Information Form. Be advised that affirmative responses may require that your application be presented to the Construction Industry Licensing Board for review.

(continued on next page)


Sample


SUPPORTING DOCUMENTATION:

Credit reports on applicant and business from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state and federal levels. Not every credit reporting agency includes this information. For a list of agencies, visit www.myflorida.com/dbpr/pro/cilb/index.html.

Make sure you have filed your electronic fingerprints with Pearson VUE. Please note that the fingerprint results are only valid for a period of six months from the date the fingerprints were submitted to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. (See page 1 of this package for additional information.)

Proof of satisfaction of liens, judgments and discharge of bankruptcy, if applicable.

Bank verification letter. (Required if you include cash on your financial statement.)

Listing of machinery and equipment. Proof that property, buildings, vehicles or life insurance is in the

name of the business if listed on the financial statement. Proof of CILB grade report indicating overall status as “passed” for all

applicable parts of examination. Grade report must be no older than three years.

Swimming Pool Specialty License applicants - provide practical examiner grade report and CILB-approved education provider certificates indicating completion of one hour each of workplace safety, business practices and worker's compensation courses.

NOTE: If the Financially Responsible Officer is not the primary qualifier for the business, the officer will need to complete DBPR CILB 4366 – Financially Responsible Officer form, pay a $200 fee and submit supporting documentation as required.

Please send your completed application, documentation and required fee(s) to:

Department of Business and Professional Regulation 1940 North Monroe Street

Tallahassee, FL 32399 – 0783

www.MyFlorida.com/dbpr


Sample

http://www.myflorida.com/dbpr

DBPR CILB 4359 – Initial Issuance of Licensure for CERTIFIED Contractors page 1 of 5 NOTE – This form must be submitted as part of an entire application packet. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

APPLICANT INFORMATION Last Name First Middle Title Suffix

Social Security Number* Telephone Number

CHECK ONLY ONE LICENSE CATEGORY For definitions and information on license categories, go to

http://www.myflorida.com/dbpr/pro/cilb/cilb_index.shtml. Class A Air-Conditioning

Class B Air-Conditioning

Building Roofing Plumbing General Mechanical

Commercial Pool/Spa

Residential Pool/Spa

Swimming Pool/Spa Servicing

Residential Sheet Metal Specialty:

Solar Water Heating

Underground Utility and Excavation

Solar Specialty: Dry

Wall Specialty:

Structure Specialty:

Glass & Glazing

Specialty: Gas Line Pollutant Storage

Systems Specialty:

Swimming Pool Layout

Specialty: Swimming Pool Structural

Specialty: Swimming Pool Excavation

Specialty: Swimming Pool Trim

Specialty: Swimming Pool Decking

Specialty: Swimming Pool Piping

Specialty: Swimming Pool Finishes

CHECK APPLICABLE TRANSACTION One box must be checked in each section below

Active Individual – DO NOT complete pages 15 – 17.

Inactive Inactive status does not apply for businesses. FOR INACTIVE STATUS ONLY, DO NOT COMPLETE THE FINANCIAL STATEMENT FORM AND DO NOT PROVIDE CREDIT REPORTS OR BANK VERIFICATION LETTER.

Business – Complete all pages. Name of Business:

INSURANCE – FOR ACTIVE STATUS ONLY

Have you obtained public liability and property damage insurance in the amounts determined by rule of the Construction Industry Licensing Board? Yes No

Minimum amounts required for General Liability Insurance: General and Building Contractors - $300,000 bodily injury; $50,000 property damage

All other Categories - $100,000 bodily injury; $25,000 property damage Have you obtained workers’ compensation insurance or filed for an exemption with the Division of Workers’ Compensation, and if not, do you attest that you will obtain an exemption within 30 days after your license is issued? Yes No

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317.

Specialty: Marine


Sample

DBPR CILB 4359 – Initial Issuance of Licensure for CERTIFIED Contractors page 2 of 5 Please give the details of your work experience history. Please refer to Section 489.111, Florida Statutes, and Rule 61G4-15.001, Florida Administrative Code.

EXPERIENCE HISTORY SUBMIT ADDITIONAL SHEETS IF NECESSARY

DESCRIBE EXPERIENCE AND WORK PERFORMED

LIST JOBS where the described Experience was gained (list number of stories if applying for GENERAL) and List the company and/or contractors that supervised your work

Name, Address & Phone

Number of Employer or

Name of Company

TIME SPENT on projects

listed FROM/TO


Sample

DBPR CILB 4359 – Initial Issuance of Licensure for CERTIFIED Contractors page 3 of 5

QUALIFICATION FOR LICENSURE CHECK ONLY ONE BOX

A person shall qualify for certification licensure by meeting one of the following requirements: 1. Four year construction-related degree from an accredited college (equivalent to three

years experience) and one year proven experience applicable to the category for which you are applying

2. One year of experience as a foreman and not less than 3 years of credits for any accredited college-level courses

3. One year experience as a workman, one year proven experience as a foreman and two years of credits for any accredited college-level courses

4. Two years experience as a workman, one year experience as a foreman and one year of credits for any accredited college-level courses

5. Four years experience as a workman or foreman of which at least one year must have been as a foreman

6. Holding an active certified Florida contractor’s license. If checked, please fill in: License #__________________Date issued__________________ If item #6 is selected: This option only applies to Certified Building, Residential, Air-

Conditioning and Swimming Pool contractors as provided in Section 489.111(2)(c)4-6, Florida Statutes.


Sample


TO BE COMPLETED BY PERSON VERIFYING EXPERIENCE AND NOTARY PUBLIC

All years of experience necessary for qualification must be verified. Applicants may submit more than one affidavit.

I __________________________________ certify that I have direct knowledge of the work (PRINT NAME OF PERSON VERIFYING EXPERIENCE)

experience of __________________________________ and that he or she meets the (PRINT APPLICANT'S NAME )

requirements for __________________________________ as set forth in Section 489.111(2)c, (TYPE OF LICENSE APPLYING FOR) Florida Statutes, and Rule 61G4-15.001, Florida Administrative Code. I further understand my license can be subject to discipline if the information given and attested to by me is found to be misleading and fraudulent. Name of individual verifying experience:

Verifier’s License Number (attach copy of license):

Verifier’s Employer (DBA Name):

Verifier’s Employer (DBA) Address: Phone Number:

Describe in detail the applicant's duties, dates of employment, and employer, including any hands on/supervisory responsibilities:


Sample


Applicant’s experience (continued): Applicant’s Years of Supervisory Experience: From ______________ To ________________ (DATE) (DATE) Notarized Signature of Person Verifying Experience: ________________________________ Date:____________ I may be reached by phone for comment, if necessary, at the telephone number shown below during business hours. REQUIRED Phone Number:___________________________

STATE OF _____________________ COUNTY OF _______________________ Sworn to (or affirmed) and subscribed before me this ______ day of _________, 20____, by ________________________________________(Name of person making statement) _____________________________________________ (Signature of Notary Public-State of ________________) (Notary Seal) _____________________________________________ (Name of Notary; typed, printed, or stamped) Personally known _____ OR produced identification ______ Type of identification produced ______________________________


Sample

DBPR 0010 – Master Individual Application page 1 of 3

STATE OF FLORIDA DEPARTMENT OF BUSINESS AND

PROFESSIONAL REGULATION

PERSONAL INFORMATION Social Security Number*

Last Name First Middle Title Suffix

Birth Date (MM/DD/YYYY) Gender Male Female

Race/Ethnicity (check only one): Black or African American White or Caucasian

Asian or Pacific Islander Spanish, Hispanic or Latino

Native American or Alaskan Native Other

MAILING ADDRESS Street Address or P.O. Box

City State Zip Code (+4 optional)

County (if Florida address) Country

CONTACT INFORMATION Primary Phone Number Primary E-Mail Address

RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS) Street Address



BUSINESS LOCATION ADDRESS Business/Firm Name

Street Address



ADDITIONAL CONTACT INFORMATION (OPTIONAL)

Alternate Phone Number Fax Number

Alternate E-Mail Address



Sample


PRIOR LICENSE INFORMATION If you currently or previously have held a business or professional license/registration in Florida or elsewhere, please list them below: 1. License/Registration Type State Date (From) Date (To)

License Number Name Used

2. License/Registration Type State Date (From) Date (To)


3. License/Registration Type State Date (From) Date (To)


BACKGROUND INFORMATION 1. Yes

(If yes, please complete form

0050-1)

No Have you ever been convicted of a crime, found guilty, or entered a plea of guilty or nolo contendere (no contest) to, even if you received a withhold of adjudication? This question applies to any violation of the laws of any municipality, county, state or nation, including felony, misdemeanor and traffic offenses (but not parking, speeding, inspection, or traffic signal violations), without regard to whether you were placed on probation, had adjudication withheld, were paroled, or pardoned. If you intend to answer “NO” because you believe those records have been expunged or sealed by court order pursuant to Section 943.058, Florida Statutes, or applicable law of another state, you are responsible for verifying the expungement or sealing prior to answering "NO." YOUR ANSWER TO THIS QUESTION WILL BE CHECKED AGAINST LOCAL, STATE AND FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE DEPARTMENT.

2. Yes (If yes, please complete form

0050-1)

No Has any judgment or decree of a court been entered against you in this or any other state, province, district, territory, possession or nation, in which you were charged in the petition, complaint, declaration, answer, counterclaim, or other pleading with any fraudulent or dishonest dealing, or is there any such case or investigation pending?


0060-1)

No Have you ever had an application for registration, certification, or licensure in Florida or in any other jurisdiction denied, or is there now pending a proceeding or investigation to deny such an application?


0060-1)

No Has any license, registration or permit to practice any regulated profession, occupation, vocation, or business been revoked, annulled, suspended, relinquished, surrendered, or withdrawn in Florida or in any other jurisdiction, or is any such proceeding or investigation now pending?

If you answered “YES” to questions 1 – 4 above, please provide the full details of any criminal conviction, lawsuit or judgment, or administrative action including the nature of any charges, dates, outcomes, sentences, and/or conditions imposed; the dates, name and location of the court and/or jurisdiction in which any proceedings were held or are pending; and the designation and/or license number for any actions against a license or licensure application. Please utilize form 0050-1 for your responses to questions 1 and 2, and form 0060-1 for your responses to questions 3 and 4. If you have more than seven offenses to document on form 0050-1, attach additional copies of form 0050-1 as necessary.

PRIOR NAME INFORMATION Have you used, been known as, or called by another name (example - maiden name, pseudonym, nickname) or alias other than the name signed to the application? Yes No If your answer is yes, state name or names used below: Last Name First Middle Title Suffix




Sample


ATTEST STATEMENT I have read the questions in this application and have answered them completely and truthfully to the best of my knowledge. I have successfully completed the education, if any, required for the level of licensure, registration, or certification sought. I have the amount of experience required, if any, for the level of licensure, registration, or certification sought. I pledge to comply with the applicable standards of practice upon licensure, registration, or certification. I understand the types of misconduct for which disciplinary proceedings may be initiated. Giving knowingly misleading statements or knowing misrepresentation when applying for a license constitutes a felony of the third degree and may result in licensure denial or revocation. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true. Signature: Print Name: Social Security Number:


Sample

DBPR CILB 4370 – CILB Financial Statement page 1 of 2

STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION

1940 North Monroe Street Tallahassee, FL 32399 – 0783 www.MyFloridaLicense.com

NOTE – This form must be submitted as part of an entire application

packet. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.



APPLYING FOR LICENSURE AS (Select Only One):

Individual – Financial Statement reflects financial condition of APPLICANT

Sole Proprietor – Financial Statement reflects financial condition of COMPANY OR OWNER

Corporation – Financial Statement reflects financial condition of CORPORATION

Partnership – Financial Statement reflects financial condition of PARTNERSHIP

As part of the Financial Statement, you must provide the following supporting documentation unless you are submitting an audited CPA prepared financial statement: • If you are showing inventory, machinery, fixtures and equipment as part of your total assets, you must

attach a listing of these items and monetary value of each to this form. • If you include “cash in bank” as part of your financial statement, you must submit a bank verification

letter that indicates the name on the account and the current account balance. The bank verification letter may be no older than three months. If you are providing a business financial statement, you must ensure that your bank account is in the legal name of the business entity.

IF YOU ARE APPLYING TO QUALIFY A CORPORATION, PARTNERSHIP, TRUST OR OTHER LEGAL ENTITY, you must also include documented proof that any property, buildings, vehicles, or life insurance is in the name of the corporation, partnership, trust, or legal entity unless you are submitting an audited CPA prepared financial statement.



Sample

DBPR CILB 4370 – CILB Financial Statement page 2 of 2

FINANCIAL STATEMENT Statement of Financial Condition Of: _______________________________________________ (Individual Name or Name of Business Being Qualified, as appropriate.) Date of Financial Statement: SSN/FEID Number:

ASSETS (Omit Cents) LIABILITIES (Omit Cents)

1. Cash in Bank – Refer to statement on previous page regarding verification of cash in bank.

$ 14. Accounts Payable $

2. Accounts and Notes Receivable

$ 15. Notes Payable to Banks and Others (i.e., vehicles/ equipment/lines of credit, etc.)

$

3. Inventory, i.e., supplies $ 16. Mortgages and Bonds Payable

$

4. US Government Securities $ 17. Unpaid Taxes $

5. Other Current Assets, i.e., vehicles (itemize)

$ 18. Wages & Interest $

$ 19. Other Liabilities (if corporation)

$

$

6. Real Estate $

7. Buildings-Net (after depreciation)

$

8. Machinery, Fixtures & Equipment (after depreciation)

$

9. Leasehold Improvements-Net (after amortization)

$

10. Cash Surrender Value of Life Insurance

$

11. Stock & Bonds $

12. Other Assets (itemize)

$

$

13. Total Assets (add items 1 thru 12 above)

$ 20. Total Liabilities (add items 14 thru 19 above)

$

21. Net Worth (Subtract Item 20 from Item 13.)

$

TOTAL from Line 13

$

TOTAL LIABILITIES/NET WORTH – Add lines 20 and 21

$

PLEASE NOTE THAT THE TOTAL ASSETS COLUMN AND TOTAL LIABILITIES/NET WORTH COLUMN MUST EQUAL THE SAME AMOUNT.


Sample

DBPR CILB 4357 – Construction Business Information Form page 1 of 4

STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION

1940 North Monroe Street Tallahassee, FL 32399 – 0783

www.MyFlorida.com/dbpr

This application must be submitted with a licensed contractor’s change of status application or a contractor’s initial licensure application.

If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.

This application is NOT required if you are applying for an individual license.



License Number

CHECK APPLICABLE TRANSACTIONS Check only one box in each section below

Certified

Registered – Attach copy of Local Competency Card.

City/County of Issuance: _______________________

Qualify a New Business

Construction Business Change of Status:

From Primary to Secondary Qualifier

From Secondary to Primary Qualifier

Add Additional Qualifier

Change Officer(s)

Change from One Qualifier to Another

Amended Corporate Name Change



Sample

BUSINESS TO BE QUALIFIED INFORMATION

Corporate Name Doing Business As (DBA)

Federal Employer ID Number (FEID)

Business No Longer Qualified

MAILING ADDRESS Street Address or P.O. Box

City State Zip Code


CONTACT INFORMATION Contact Name

Primary Phone Number Primary E-Mail Address

RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS) Street Address

City State Zip Code


BUSINESS LOCATION ADDRESS Street Address

City State Zip Code


ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number

Alternate E-Mail Address

INSURANCE

Have you obtained public liability and property damage insurance in the amounts determined by rule of the Construction Industry Licensing Board? Yes No

Minimum amounts required for General Liability Insurance: General and Building Contractors - $300,000 bodily injury; $50,000 property damage

All other Categories - $100,000 bodily injury; $25,000 property damage Have you obtained workers’ compensation insurance or filed for an exemption with the Division of Workers’ Compensation, and if not, do you attest that you will obtain an exemption within 30 days after your license is issued? Yes No



Ownership: Sole Proprietorship Corporation Partnership

Sample

PRIMARY QUALIFYING AGENT / FINANCIALLY RESPONSIBLE OFFICER

Name of person legally appointed as the qualifier to act for the business organization in all matters connected with its contracting business, and who has been given authority to supervise all construction work performed by the business (this must be the applicant or a licensed contractor): Primary Qualifying Agent Name

License Number (if applicable)

Does the primary qualifying agent also have final approval authority on all business matters, including contracts, specifications, checks, drafts, or payments, regardless of the form of payment, made by the entity? Yes No If no, you must appoint a Financially Responsible Officer by completing form DBPR CILB 4366 – Financially Responsible Officer Application Package and returning it to our office with your application. This will alleviate the licensed qualifier’s financial responsibility, but the qualifier will still be responsible for all construction-related matters. Name of Financially Responsible Officer (if different than primary qualifier):

SECONDARY QUALIFYING AGENT (OPTIONAL) Name of person legally appointed as a secondary qualifier and is responsible only for the supervision of fieldwork at sites where his or her license was used to obtain the building permit and any other work for which he or she accepts responsibility (this must be the applicant or a licensed contractor): Secondary Qualifying Agent Name

License Number (if applicable)

A secondary qualifying agent is not responsible for the supervision of financial matters.

ORGANIZATIONAL RELATIONSHIPS Do you qualify any business other than the business you are applying to qualify? (If yes, complete DBPR CILB 4353 – Qualify Additional Business Organization form) Yes Name of Business: ___________________________ No

BUSINESS OWNERSHIP List below the business owners and percentage of ownership for each. TOTAL MUST EQUAL 100%.

Name of Owner & Title Address Social Security No. *

% of Ownership



Sample

FINANCIAL RESPONSIBILITY/BACKGROUND QUESTIONS

NOTE: If you answer “Yes” to any of the questions below, you must provide an explanation on DBPR 0060 – General Explanatory Description form and attach legal documentation (i.e., satisfaction of lien, judgment, payment schedule, etc.) The following persons must answer the financial responsibility questionnaire: Qualifying Agent/Applicant All Business Officers (President, Secretary, etc.) Indicate your response by circling "Yes" or "No" on the grid provided below. Have you, or a partnership in which you were a partner, or an authorized representative, or a corporation in which you were an officer or an authorized representative ever: 1. Undertaken construction contracts or work that a third party, such as a bonding or surety company, completed or made financial settlements? 2. Had claims or lawsuits filed for unpaid past-due bills by your creditors as a result of construction operations? 3. Undertaken construction contracts or works which resulted in liens, suits or judgments being filed? (If yes, you must attach a copy of the Notice of Lien and any payment agreement, satisfaction, Release of Lien or other proof of payment.) 4. Had a lien filed against you by the U.S. Internal Revenue Service or Florida Corporate Tax Division? 5. Made an assignment of assets in settlement of construction obligations for less than the debts outstanding? 6. Been charged with or convicted of acting as a contractor without a license, or, if licensed as a contractor in this or any other state, been subject to any disciplinary action by a state, county, or municipality? (If yes, you must attach a copy of any state, county, municipal or out-of-state disciplinary order or judgment.) 7. Filed for or been discharged in bankruptcy within the past five years? (If "yes", you must attach a copy of the Discharge Order, Order Confirming Plan, or if a Corporate Chapter 7 case, a copy of the Notice of Commencement.) 8. Been convicted or found guilty of or entered a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction? Indicate your response by circling “Yes” or “No”

Question Number: 1 2 3 4 5 6 7 8

Applicant – Print Name

Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Officer – Print Name

Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes


Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes


Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes


Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No Yes

No



Sample

DBPR 0050 – Explanatory Information for Background Questions page 1 of 1


PROFESSIONAL REGULATION NOTE – This form must be submitted as part of an

application packet.

PERSONAL INFORMATION Last Name First Middle Title Suffix

Identify question number on form DBPR 0010 this explanation pertains to:

EXPLANATION

Offense

County State

Penalty/Disposition

Date of Offense (MM/DD/YYYY) Have all sanctions been satisfied? Yes No

Description

EXPLANATION

Offense

County State

Penalty/Disposition

Date of Offense (MM/DD/YYYY) Have all sanctions been satisfied? Yes No

Description

Attach additional sheets as necessary


Sample

DBPR 0060 – General Explanatory Description page 1 of 1


PROFESSIONAL REGULATION NOTE – This form must be submitted as part of an

application packet.


EXPLANATION


Sample



Issuing Office


General Notes


Application to Collect And/Or ReportTax (State, FL)

Sample

APPLICATION TO COLLECTAND/OR REPORT TAX IN FLORIDA

You may be required to register to collect, accrue, and remit the taxes or fees listed below if you are engaged in any of the activities listed beneath each tax or fee.

DR-1R. 09/09

Unemployment TaxComplete Sections

A, D, and HNO fee

•Paidwagesof$1,500inanyquarteroremployedatleastoneworkerfor20weeksinacalendaryear.(Paymentsmadetocorporateofficersarewages.)

•Applicantisagovernmentalentity,Indiantribeortribalunit.

•Holdasection501(c)(3)exemptionfromfederalincometaxandemployfourormoreworkersfor20weeksinacalendaryear.

•Agriculturalemployerwitha$10,000cashquarterlypayroll,orwhoemploysfiveormoreworkersfor20weeksinacalendaryear.

•Privatehomeorcollegeclubthatpaid$1,000cashinaquarterfordomesticservices.

•Acquiredallorpartoftheorganization,trade,business,orassetsofaliableemployer.

•Liableforfederalunemploymenttaxes.•Previouslyliableforunemploymenttaxin

theStateofFlorida.

Use TaxComplete Sections

A, B, and HNO fee

•Anytaxablepurchasesthatwerenottaxedbytheselleratthetimeofpurchase.

•RepeateduntaxedpurchasesthroughtheInternetorfromout-of-statevendors.

•Anypurchasesoriginallyforresale,butlaterusedorconsumedbyyourbusinessorforpersonaluse.

•Useofdyeddieselfuelforoff-roadpurposes.

Sales TaxComplete Sections

A, B, and HPay $5 fee

(in-state only)*

•Sales,leases,orlicensestousecertainpropertyorgoods(tangiblepersonalproperty).

•Salesandrentals/admissions,amusementmachinereceipts,orvendingmachinereceiptsforalltaxableitems.

•Repairoralterationoftangiblepersonalproperty.

•Leasesorlicensestousecommercialrealproperty(includesmanagementcompanies).

•Rentaloftransient(sixmonthsorless)livingorsleepingaccommodations(includesmanagementcompanies).Alocaltouristdevelopmenttax(bedtax)mayalsoapply.Contactthetaxingauthorityinthecountywherethepropertyislocated.

•Salesorrentalofself-propelled,power-drawn,orpower-drivenfarmequipment.

•Salesofelectricpowerorenergy.•Salesofprepaidtelephonecallingcards.•Salesofcommercialpestcontrolservices,

nonresidentialbuildingcleaningservices,commercial/residentialburglaryandsecurityservices,ordetectiveservices.

•Salesofsecondhandgoods.Asecondhanddealerregistration(FormDR-1S)mayalsoberequired.

*Note: If you are registering an in-state business or property location, you must submit a $5 fee with this application. Online registration is free.

Documentary Stamp TaxComplete Sections

A, F, and HNO fee

•Enteringintowrittenfinancingagreements(fiveormoretransactionspermonth).

•Makingtitleloans.•Self-financingdealers(buyhere–payhere).•Banks,mortgagecompanies,andconsumer

financecompanies.•Promissorynotes.

Solid Waste Fees and Pollutants Tax

Complete SectionsA, B, C, and H

Pay $30 fee (drycleaning only)*

•Salesofnewtiresformotorvehicles.•Salesofneworremanufacturedlead-acid

batteries.•Rentalorleaseofmotorvehiclestoothers.•Salesofdry-cleaningservices(plantsor

drop-offfacilities).*Note: You must submit a $30 fee with this application. Online registration is free.

Gross Receipts TaxNew for 2006

Complete SectionsA, E, and H

NO fee

•Salesordeliveryofelectricityorgas.•Importation/severanceofelectricityor

naturalgasforone’sownusewheregrossreceiptstaxhasnotbeenpaid.

Communications Services Tax

Complete SectionsA, G, and H

NO fee

•Salesofcommunicationsservices(telephone,paging,certainfacsimileservices,videoconferencing).

•Salesofcableservices.•Salesofdirect-to-homesatelliteservices.•Resellers(forexample,paytelephonesand

prepaidcallingarrangements).•Seekingadirectpaypermit.

Who must apply?

You can file this application online, via the Department’s Internet site at www.myflorida.com/dor/eservices/apps/register. There is no fee for Internet registration. See instructions, next page.

RegisterOnlineIt’s FREE, fast, easy,and secure

Sample

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How can I register online?TheDR-1applicationisontheDepartment’swebsiteat www.myflorida.com/dor/eservices/apps/register.Aninteractivewizardwillguideyouthroughanapplicationfromstarttofinish.Beforeyoubegin,gatherspecificinformationaboutyourbusinessactivities,location,andbeginningdates.There are no fees for online registration.

Salesandusetaxcertificatenumberswillbeissuedwithinthreebusinessdaysofyouronlinesubmission.Afterthattime,youcanreturntothesiteandretrieveyourcertificatenumber.

How can I be sure that the information I submit online is secure?TheDepartment’sInternetregistrationsiteuses128-bitsecuresocketlayertechnologyandhasbeencertifiedbyVeriSign,anindustryleaderindatasecurity.

If a husband and wife jointly operate and own a business, what type of ownership must we indicate?Normally,whenahusbandandwifejointlyownandoperateabusiness,theownershipisa“partnership.”WesuggestyoucontacttheInternalRevenueServiceformoreinformationonpartnershipreportingrequirements.

What will I receive from the Department once I register?1. ACertificate of Registrationornotificationof

liabilityforthetax(es)forwhichyouregistered.

Alachua Service Center14107 US Highway 441 Ste 100Alachua FL 32615-6390386-418-4444 (ET)

Clearwater Service CenterArbor Shoreline Office Park19337 US Highway 19 N Ste 200Clearwater FL 33764-3149727-538-7400 (ET)

Cocoa Service Center2428 Clearlake Rd Bldg MCocoa FL 32922-5731321-504-0950 (ET)

Coral Springs Service CenterFlorida Sunrise Tower3111 N University Dr Ste 501Coral Springs FL 33065-5096954-346-3000 (ET)

Daytona Beach Service Center1821 Business Park BlvdDaytona Beach FL 32114-1230386-274-6600 (ET)

Fort Myers Service Center2295 Victoria Ave Ste 270Fort Myers FL 33901-3871239-338-2400 (ET)

Fort Pierce Service CenterBenton Building337 N US Highway 1 Ste 207-BFort Pierce FL 34950-4255772-429-2900 (ET)

Hollywood Service Center*Taft Office Complex6565 Taft St Ste 300Hollywood FL 33024-4044 954-967-1000 (ET)*Office closing November 30, 2009

Jacksonville Service Center921 N Davis St A250Jacksonville FL 32209-6829904-359-6070 (ET)

Key West Service Center3104 Flagler Ave Key West FL 33040-4602305-292-6725 (ET)

Lake City Service Center1401 W US Highway 90 Ste 100Lake City FL 32055-6123386-758-0420 (ET)

Lakeland Service Center115 S Missouri Ave Ste 202Lakeland FL 33815-4600863-499-2260 (ET)

Leesburg Service Center1415 S 14th St Ste 103Leesburg FL 34748-6686352-315-4470 (ET)

Maitland Service CenterSte 1602301 Maitland Center ParkwayMaitland FL 32751-4192407-475-1200 (ET)

Marianna Service Center4230 Lafayette St Ste DMarianna FL 32446-8231850-482-9518 (CT)

Miami Service Center8175 NW 12th St Ste 119Miami FL 33126-1828305-470-5001 (ET)

Naples Service Center3073 Horseshoe Dr S Ste 110Naples FL 34104-6145239-434-4858 (ET)

Orlando Service CenterRegions Bank Building5401 S Kirkman Rd 5th FloorOrlando FL 32819-7911407-903-7350 (ET)

Panama City Service Center210 N Tyndall ParkwayPanama City FL 32404-6432850-872-4165 (CT)

Pensacola Service Center3670C N L StPensacola FL 32505-5217850-595-5170 (CT)

Port Richey Service Center6709 Ridge Rd Ste 300Port Richey FL 34668-6842727-841-4407 (ET)

Sarasota Service CenterSarasota Main Plaza1991 Main St Ste 240Sarasota FL 34236-5940941-361-6001 (ET)

Tallahassee Service Center267 John Knox Rd Ste 200Tallahassee FL 32303-6692850-488-9719 (ET)

Tampa Service CenterSte 1006302 E Martin Luther King BlvdTampa FL 33619-1166813-744-6590 (ET)

West Palm Beach Service Center2468 Metrocentre BlvdWest Palm Beach FL 33407-3105561-640-2800 (ET)

CT —Central TimeET—Eastern Time

FLORIDA DEPARTMENT OF REVENUE SERVICE CENTERS

2. Personalizedreturnsorreportsforfiling,withinstructions.

3. Foractivesalestaxandcommunicationsservicestaxdealers,anAnnual Resale CertificatewillaccompanytheCertificate of Registration.

What is an Annual Resale Certificate?TheDepartmentissuesAnnual Resale Certificatestoactive,registeredsalestaxdealersandcommunicationsservicestaxdealers.TheAnnual Resale Certificateallowsbusinessestomaketax-exemptpurchasesfromtheirsuppliers,providedtheitemorserviceispurchasedforresale.AcopyofacurrentAnnual Resale Certificatemustbeextendedtothesupplier;otherwise,taxmustbepaidonthetransactionatthetimeofpurchase.TaxInformationPublication(TIP)99A01-34explainstheresaleprovisionsforsalesandusetax.TIP01BER-01explainstheresaleprovisionsforcommunicationsservicestax.ConsulttheDepartment’sInternetsiteforfurtherinformation.Misuse of the Annual Resale Certificate will subject the user to penalties as provided by law.

What are my responsibilities?1. Youmustregisterforalltaxesforwhichyou

areliablebeforebeginningbusinessactivities,otherwiseyoumaybesubjecttopenalties.Formoreinformation,visitourInternetsiteorcontactTaxpayerServices.

2. CompleteandreturnthisapplicationtotheFloridaDepartmentofRevenuewiththeapplicableregistrationfee.IFMAILING,DONOTSENDCASH.SENDCHECKORMONEYORDER.

Account Management5050 W Tennessee StTallahassee, FL 32399-0100850-488-9750

Taxpayer Services800-352-3671 orTDD: 800-367-8331

Internet Sitewww.myflorida.com/dorTax Law Librarywww.myflorida.com/dor/law

3. Collectand/orreporttaxappropriately,maintainaccuraterecords,postyourcertificate(ifrequired),andfilereturnsandreportstimely.A return/report must be filed even if no tax is due.

4. NotifytheDepartmentifyouraddresschanges,yourbusinessentityoractivitychanges,youopenadditionallocations,oryoucloseyourbusiness.

5. Provideyourcertificateoraccountnumberonallreturns,remittances,andcorrespondence.

What if my business has more than one location? Sales tax:Youmustcompleteaseparateapplicationforeachlocation.Gross receipts tax on electric power or gas:Youhavetheoptionofregisteringalllocationsunderoneaccountnumberorseparatelyregisteringeachlocation.Documentary stamp tax:Youmustregistereachlocationwherebooksandrecordsaremaintained.Communications services tax and unemployment tax:YoumustregistereachentitythathasitsownFederalEmployerIdentificationNumber(FEIN).Solid waste fees and pollutants tax (rental car surcharge):Youmustregisterforeachcountywhereyouhavearentallocation.

What if I am managing commercial or residential rental property for others? Forsalestax,commercialpropertymanagersmustusethisapplication;residentialpropertymanagersmayuseFormDR-1C,Application for Collective Registration for Rental of Living or Sleeping Accommodations.ContactAccountManagementat850-488-9750forassistance.

Sample

8 0

8. IfyouhaveaConsolidated Sales Tax Numberandwanttoincludethisbusinesslocation,pleasecompletethefollowing:

ConsolidatedregistrationnameonrecordwiththeFloridaDepartmentofRevenue. Consolidatedregistrationnumber Ifyouwanttoobtainanewconsolidatednumber,contacttheDepartmentandrequestFormDR-1CON.

9. Business Entity Identification Number. Ifyouareregisteringforunemploymenttaxorhaveemployees,youmustprovideanFEIN.IfanFEINisnotrequiredforyourbusinessentity,thesocialsecuritynumberoftheownerisrequired.PleasereadtheexplanationoftheDepartment’suseofsocialsecuritynumbers*onPage6.

a. FederalEmployerIdentificationNumber(FEIN): –

b. SocialSecurityNumber(SSN)ofowner: –

–

–

–

** P

LEA

SE

TY

PE

OR

PR

INT

CLE

AR

LY *

*

7. Mailing address (ifdifferentthanphysicaladdress):

4. Legal name of corporation, individual owner (last,first,middle) limited liability company, partnership, or other:

5. Trade or fictitious name (d/b/a) (ifdifferentthan#4above):

6. Complete physical address of business or real property.Home-basedbusinessesandnon-permanentfleamarket/craftshowvendorsmustusetheirhomeaddresses.Listingapostofficebox,privatemailbox,orruralroutenumberisnotpermitted.

Owner telephone number:

Business telephone number:

City/State/ZIP: County:

Mailing address:

City/State/ZIP:

Fax number:

E-mail address:

APPLICATION TO COLLECT AND/OR REPORT TAX IN FLORIDASECTION A — BUSINESS INFORMATION

New Registration

A.

Newbusiness B. Newbusiness C. Newtaxobligation

entity location atexistinglocation

ProvidecertificatenumberifyoucheckedBorC:

–

–

Beginning date of business activity:

month day year

ProvidethedatethisbusinesslocationorentitybecameorwillbecomeliableforFloridatax(es).Donotuseyourincorporationdateunlessthatisthedateyourbusinessbecameliablefortax.If you have been in business longer than 30 days prior to registering, contact the DOR service center nearest you.

2. Indicatewhetherthisisanewregistration(neverbeforeregisteredwiththeFloridaDepartmentofRevenue)orachangetoanexistingregistration.

Change to Existing Registration D.

Changeofcountylocation E.

Changeof F. Changeof

(Businessismovingfrom legalentity ownership oneFloridacountytoanother)

IfyouhavecheckedBoxD,E,orF,theDepartmentwillcancelyourexistingcertificate(s)andissueanewone.Providethecertificatenumber(s)tobecanceled.

(Attachadditionalsheetifnecessary.)

–

–

This change is effective (enter date):

month day year

3. Ifthisisaseasonalbusiness(notopenyear-round),listthemonthsofyouropenseason.

Beginningdate: Endingdate: month day year month day year

*The $5 registration fee does not apply if:•Your business location is outside

the State of Florida.•Your business is moving from

one Florida county to another.•You register online.

**The $30 registration fee applies to drycleaning only. There is no fee for online registration.

Please use BLACK or BLUE ink ONLY and type or print clearly.

Answer ALL questions in the section(s) that apply to your business.

1. This application is for (check all that apply):

DR-1 R. 09/09

Page 1

If your business is relocating within the same county, do not use this application. Contact the Department to change your address.

✓ Tax Type Fee DueComplete Sections

SalesandUseTax $5.00* A,B,HUseTaxOnly Nofee A,B,HSolidWasteFeesandPollutantsTax $30.00** A,B,C,HUnemploymentTax Nofee A,D,HGrossReceiptsTaxonElectricPowerandGas Nofee A,E,HDocumentaryStampTax Nofee A,F,HCommunicationsServicesTax Nofee A,G,H

(IfyouarerequiredtohaveanFEIN,buthavenotyetbeenassignedoneyoumaycalltheInternalRevenueServiceat800-829-4933torequestone.)

or

Sample

SECTION A — BUSINESS INFORMATION (CONT’D.)DR-1

R. 09/09Page 2

10. Identifyproprietorsorowners,partners,officers,members,ortrustees.IncludethepersonwhosesocialsecuritynumberislistedunderQuestion9.Without this information, processing of your application may be stopped. (See Page 6*)

12. Ifapartnership,corporation,orlimitedliabilitycompany,provideyourfiscalyearendingdate: month day

11. Type of ownership-Checktheboxnexttotheexactentitystructureofyourbusiness.

14. Isyourbusinesslocationrentedfromanotherpersonorentity?Yes No Ifyes,andyoudo not operate from your home,providethefollowinginformation.

Ownerorlandlord’sname_________________________________________________________Telephonenumber__________________________

Address________________________________________________________________________City/State/ZIP_____________________________

15. a. Whatisyourprimarybusinessactivity? ____________________________________________________________________________________

b. Whatareyourtaxablebusinessactivities?___________________________________________________________________________________

c. Ifknown,enteryourNorthAmericanIndustryClassificationSystem(NAICS)Code:________________________________________________ TodetermineyourNAICScode,gotohttp://www.naics.com/search.htm

13. Ifincorporated,charteredorotherwiseregisteredtodobusinessinFlorida,provideyourdocument/registrationnumberfromtheFloridaSecretaryofState:

_________________________________________________________

Providethedateofincorporation,charter,orauthorizationtodobusinessinFlorida:

month day year

Note:Ifnotincorporated,charteredorregisteredtodobusinessinFlorida,youmayberequiredtodoso.CalltheFloridaDepartmentofState,DivisionofCorporationsat850-488-9000formoreinformationorvisitwww.sunbiz.org

Sole proprietorship-Anunincorporatedbusinessthatisownedbyoneindividual.

Partnership -Therelationshipexistingbetweentwoormoreentitiesorindividualswhojointocarryonatradeorbusiness.Thisincludesabusinessjointlyowned/operatedbyahusbandandwife.

Checkone: Generalpartnership Limitedpartnership

Jointventure Marriedcouple

Corporation -Apersonorgroupofpeoplewhoincorporatebyreceivingacharterfromtheirstate’sSecretaryofState(includesprofessionalservicecorporations).

Checkone: C-corporation S-corporation

Not-for-profitcorporation

Limited liability company-Twoormoreentities (orindividuals)whofilearticlesoforganizationwiththeirstate’sSecretaryofState.

Checkone: Single-memberLLC Multi-memberLLC

Checkhereifyouelectedtobetreatedasacorporationforfederalincometaxpurposes.

Business trust-Anentitycreatedunderanagreementoftrustforthepurposeofconductingabusinessforprofit(includesrealestateinvestmenttrusts).

Non-business trust/Fiduciary-Anentitycreatedbyagrantorforthespecificbenefitofadesignatedentityorindividual.

Estate -Anentitythatiscreateduponthedeathofanindividual,consistingofthatindividual’srealorpersonalproperty.

Dateofdeath:__________________

Government agency-Alegalgovernmentbodyformedbygoverningconstitutions,statutes,orrules.

Indian tribe or Tribal unit-AnyIndiantribe,band,nation,orotherorganizedgrouporcommunitywhichisrecognizedaseligibleforthespecialprogramsandservicesprovidedbytheUnitedStatestoIndiansbecauseoftheirstatusasIndians(includesanysubdivision,subsidiary,orbusinessenterprisewhollyownedbysuchanIndiantribe).

NameTitle

Social security number* andDriver license number and state

Home addressCity/State/ZIP Telephone number

(___)___-____

(___)___-____

(___)___-____

(___)___-____

Sample

SECTION B — SALES AND USE TAX ACTIVITY — $5 FEE (IN-STATE ONLY)

SECTION C — SOLID WASTE FEES AND POLLUTANTS TAX —

a. Salesofpropertyorgoodsatretail(toconsumers)?

b. Salesofpropertyorgoodsatwholesale(toregistereddealers)?

c. Salesofsecondhandgoods?

d. Rentalofcommercialrealpropertytoindividualsorbusinesses?

e. Rentaloftransientlivingorsleepingaccommodations(forsixmonthsorless)?

f. Managementoftransientlivingorsleepingaccommodationsbelongingtoothers?

g. Rentalofequipmentorotherpropertyorgoodstoindividualsorbusinesses?

DR-1 R. 09/09

Page 316. Doesyourbusinessactivityinclude(checkallthatapply):

17. Whatproductsorservicesdoyoupurchaseforresale?__________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

$30 FEE FOR DRYCLEANING ONLY

h. Renting/leasingmotorvehiclestoothers?

i. Repairoralterationoftangiblepersonalproperty?

j. Chargingadmissionormembershipfees?

k. Placingandoperatingcoin-operatedamusementmachinesatbusinesslocationsbelongingtoothers?

l. Placingandoperatingvendingmachinesatbusinesslocations belongingtoothers?

m. Purchasingitemstobeincludedinafinishedproductassembledormanufacturedforsale?

n. Providinganyofthefollowingservices?(Checkallthatapply.)

n1. Pestcontrolfornonresidentialbuildings

n2. Cleaningservicesfornonresidentialbuildings

n3. Detectiveservices

n4. Protectionservices

n5. Securityalarmsystemmonitoring

o. Purchasingitemsthatwerenottaxedbythesellerattimeofpurchase(includes,butisnotlimitedto,purchasesthroughtheInternet,fromcatalogs,orfromout-of-statesellers)?

p. Usingdyeddieselfuelforoff-roadpurposes?

q. Operatingvendingmachine(s)ownedbyyouatyourbusinesslocation?

COIN-OPERATED AMUSEMENT MACHINES

18. Are coin-operated amusement machines being operated at your business location? If yes, answer question 19. .......... Yes No

19. Doyouhaveawrittenagreementthatrequiressomeoneotherthanyourselftoobtainamusementmachine

certificatesforanyofthemachinesatyourlocation?Ifyes,providetheirinformationbelow.................................................. Yes No

_____________________________________ _______________________________ __________________________ Name Address Telephonenumber

Note:YoumustcompleteanApplication for Amusement Machine Certificate(FormDR-18)ifyouansweredYEStoquestion18andNOtoquestion19.

CONTRACTORS

20. Do you improve real property as a contractor? If yes, answer questions 21-23. ................................................................ Yes No21. Doyouselltangiblepersonalpropertyatretail?......................................................................................................................... Yes No

22. DoyoupurchasematerialsorsuppliesfromvendorslocatedoutsideofFlorida?...................................................................... Yes No

23. Doyoufabricateormanufactureanybuildingcomponentatalocationotherthancontractsites?............................................ Yes NoMOTOR FUEL

24. Do you sell any type of fuel or use off-road, dyed, diesel fuel? If yes, answer questions 25 and 26. ................................ Yes No25. a. Doyoumakeretailsalesofgasoline,dieselfuel,oraviationfuelatpostedretailprices?.................................................... Yes No

b. Ifyesto#25a,doesthisbusinessexistasamarina?.............................................................................................................. Yes No

c. Ifyesto#25a,doyouexpecttosellmoredieselfuelthangasoline?.................................................................................... Yes No

d. Ifyesto#25a,provideyourFloridaDepartmentofEnvironmental Protectionfacilityidentificationnumberforthislocation.

26. Doyouusedyeddieselfuelforoff-roadpurposesthatwasnottaxedatthetimeofpurchase?................................................ Yes No

27. Do you sell tires or batteries, or rent/lease motor vehicles to others? If yes, answer questions 28-30. ............................. Yes No28. Doyoumakeretailsalesofnewtiresformotorizedvehicles(eitherseparatelyorasapartofavehicle)?............................... Yes No29. Doyoumakeretailsalesofneworremanufacturedlead-acidbatteriessoldseparatelyorasacomponentpartof

anotherproductsuchasnewautomobiles,golfcarts,boats,etc.?.............................................................................................. Yes No30. Areyouinthebusinessofrentingorleasingvehiclesthattransportfewerthanninepassengers toindividualsorbusinesses?....................................................................................................................................................... Yes No

31. Do you own or operate a dry-cleaning dry drop-off facility or plant in Florida? ............................................................... Yes No If yes, enclose the $30 dry-cleaning registration fee.32. Do you produce or import perchloroethylene? ....................................................................................................................... Yes No If yes, you must complete an Application for Florida License to Produce or Import Taxable Pollutants (Form DR-166).

Sample

SECTION D — UNEMPLOYMENT TAX — NO FEEDR-1

R. 09/09Page 4

If you are registering an additional business location and are already registered with the Florida Department of Revenue for unemployment tax, you do not need to complete this section.

If you need to reactivate a previously assigned unemployment tax (UT) account number, enter your account number and complete items 33-41 below. Make sure that you have entered your FEIN on page 1, item 9.

33. Employertype(checkallthatapply):

Regular(Ifaleasingcompany, Agricultural(citrus) Governmentalentity Nonprofitorganization attachcopyoflicense.) (501(c)(3)lettermustbeattached)

Domestic(household) Agricultural(noncitrus) Agriculturalcrewchief Indiantribe/Tribalunit

34. Didyourbusinesspayfederalunemploymenttaxinanotherstateinthecurrentorpreviouscalendaryear?........................... Yes No

Ifyes,inwhichstate(s) _______________________________________________________________ Year(s)_________________________

35. Doyouleaseanyofyouremployees? Yes NoIfyes,checkwhetherallorpartofyourworkforceisleased:.......... All Part

LeasingCompanyName:__________________________________________ DBPRLicenseNumber:____________________________________

Dateleasingbegan: ______________________________________________ LeasingCompany’sFEIN:_________________________________

LeasingCompany’sUTAcct.Number:_______________________________

36. Forthecurrentcalendaryear,howmanyfullorpartialweekshaveyouemployedworkers? _____________________________________________

Forthepreviousyear,howmanyfullorpartialweeksdidyouemployworkers?_______________________________________________________

37. ProvidethedatethatyoufirstemployedorwillemployworkersinFlorida. month day year

38. Doesanotherparty(accountant,bookkeeper,agent)maintainyourpayroll?........................................................................... Yes No Ifyes,providethefollowinginformation.

Nameofagent __________________________________________ Telephonenumber__________________________________

Address_______________________________________________ City/State/ZIP _________________________________________________

39. ProvideonlyyourFloridagrosspayrollbycalendarquarters.Estimateamountsifexactfiguresarenotavailable.

Qtr Ending 3/31 Qtr Ending 6/30 Qtr Ending 9/30 Qtr Ending 12/31

Currentyear $ $ $ $

Previousyear $ $ $ $

Nextpreviousyear $ $ $ $



40. Didyoupurchasethisbusinessfromanotherentityorchangeyourcurrentbusinessstructureinanyway?............................ Yes No Ifyes,completeitemsathroughibelow,providinginformationabouttheformerentity.Also,completeandsubmitaReport to Determine

Succession and Application for Transfer of Experience Rating Records(FormUCS-1S)totheDepartmentofRevenue.Thisformmustbepostmarkedwithin90daysoftheacquisitiondatetobeconsideredtimely.

a. Legalnameofformerentity_____________________________________________________________________________________________

b. FEIN______________________________________________ c. UTaccountnumber__________________________________________

d. Tradename(d/b/a)____________________________________________________________________________________________________

e. Address_____________________________________________________________________________________________________________

f. Dateofpurchase/change________________________________ g. Portionofbusinessacquired: All Part Unknown

h. Wasthebusinessinoperationatthetimethepurchase/changeoccurred? Yes NoIfno,providedatebusinessclosed._____________

i. Wasthereanycommonownership,management,orcontrolatthetimethepurchase/changeoccurred? Yes No

41. List the locations and nature of business conducted in Florida. Use additional sheets if necessary. Address,city,andcountyofworksite Principalproducts/services Numberofemployees ________________________________________ _____________________________________________ ____________________________

________________________________________ _____________________________________________ ____________________________

________________________________________ _____________________________________________ ____________________________

Dotheaboveworksitesprovidesupportforanyotherunitsofthecompany?......................................................................... Yes No

Ifyes,theservicesare: administrative research other,specify _________________________________________________________

____________________________________________________________________________________________________________________

Sample

SECTION F — DOCUMENTARY STAMP TAX — NO FEE

SECTION G — COMMUNICATIONS SERVICES TAX — NO FEE

SECTION E — GROSS RECEIPTS TAX — NO FEE DR-1

R. 09/09Page 5

42. Do you sell, deliver, or transport electricity or gas? If yes, check the items below that apply:.......................................... Yes No a. Electricity............................................................................................................................................................................... Yes No

b. Naturalormanufacturedgas?................................................................................................................................................ Yes No43. Doyouimportintothisstate,naturalormanufacturedgasforyourownuseasasubstituteforpurchasing taxableutilityortransportationservices?.................................................................................................................................... Yes No

44. Do you make sales, finalized by written agreements, that do not require recording by the Clerk of the Court, but do require documentary stamp tax to be paid? If yes, answer questions 45-47. ......................... Yes No

45. Doyouanticipatefiveormoretransactionssubjecttodocumentarystamptaxpermonth?...................................................... Yes No

46. Doyouanticipateyouraveragemonthlydocumentarystamptaxremittancetobelessthan$80permonth?.......................... Yes No

47. Isthisapplicationbeingcompletedtoregisteryourfirstlocationtocollectdocumentarystamptax?...................................... Yes No If no, and this application is for additional locations, please list name and address of each additional location. (Attachadditionalsheetsifneeded.)

Locationname__________________________________________ Telephonenumber_____________________________________________

Physicaladdress_________________________________________ City/State/ZIP ________________________________________________

48. Do you sell communications services? If yes, check the items below that apply. ........................................................................ Yes No

a. Telephoneservice(local,longdistance,ormobile)............................................................................................................... Yes No

b.Pagingservice........................................................................................................................................................................ Yes No

c. Facsimile(fax)service(notinthecourseofadvertisingorprofessionalservices)............................................................... Yes No

d.Cableservice.......................................................................................................................................................................... Yes No

e. Direct-to-homesatelliteservice............................................................................................................................................. Yes No

f. Paytelephoneservice............................................................................................................................................................. Yes No

g. Reseller(onlysalesforresale;nosalestoanyretailcustomers)........................................................................................... Yes No

h.Otherservices;pleasedescribe:_____________________________________________________________________ Yes No

49. Doyoupurchasecommunicationsservicestointegrateintoprepaidcallingarrangements?..................................................... Yes No

50. Areyouapplyingforadirectpaypermitforcommunicationsservices?................................................................................... Yes No

51. Checktheappropriatebox(es)forthemethod(s)youintend tousefordeterminingthelocaltaxingjurisdictionsinwhichserviceaddressesforyourcustomersarelocated.Ifyouusemultipledatabases,checkallthatapply.Ifyouonlysellpaytelephoneordirect-to-homesatelliteservices,provideprepaidcallingarrangements,areareseller,orareapplyingforadirectpaypermit,skipquestions51and52.

1. AnelectronicdatabaseprovidedbytheDepartment.

2a.Adatabasedevelopedbythiscompanythatwillbecertified.Toapplyforcertificationofyourdatabase,completeanApplication for Certification of Communications Services Database (FormDR-700012).

2b.Adatabasesuppliedbyavendor.Providethevendor’sname:

________________________________________________

3. ZIP+4andamethodologyforassignmentwhenZIPcodesoverlapjurisdictions.

4. ZIP+4thatdoesnotoverlapjurisdictions.Example:ahotellocatedinonejurisdiction.

5. Noneoftheabove.

Twocollectionallowanceratesareavailable.

•Dealerswhosedatabasesmeetthecriteriainitems1,3,or4aboveareeligiblefora.75percent(.0075)collectionallowance.

•Dealerswhosedatabasesmeetthecriteriainitem5areeligiblefora.25percent(.0025)collectionallowance.

•Dealersmeetingthecriteriainitem2aareeligiblefora.25percent(.0025)collectionallowanceuntilthedatabaseiscertified.Uponcertification,thedealerwillreceivethe.75percent(.0075)collectionallowance.

•Dealersmeetingthecriteriain2bareeligibleforthe.75percent(.0075)collectionallowanceifthevendor’sdatabasehasbeencertified.Ifnot,the.25percentcollectionallowance(.0025)willapply.

Dealerswithmultipledatabasesmayneedtofiletwoseparatereturnsinordertomaximizetheircollectionallowances.

•IfalldatabasesarecertifiedoraZIP+4methodisused,thenthedealerisentitledtothe.75percent(.0075)collectionallowance.

•IfsomedatabasesarecertifiedoraZIP+4methodisused,andsomearenot,thedealerhastwooptionsforreportingthetax.Oneistofileasinglereturnforalltaxablesalesfromalldatabasesandreceivea.25percent(.0025)collectionallowance.Thesecondoptionistofiletworeturns:onereportingtaxablesalesfromcertifieddatabases(.75percentallowance)andaseparatereturnforthetaxablesalesfromnon-certifieddatabases(.25percentallowance).

•Ifnodatabasesarecertified,thedealerwillreceivea.25percent(.0025)collectionallowanceonalltaxcollected.

52. If you wish to be eligible for both collection allowances, check the box below to indicate that you will file two separate returns.

Iwillfiletwoseparatecommunicationsservicestaxreturnsinordertomaximizemycollectionallowance.

53. Providethenameofthemanagerialrepresentativewhocananswerquestionsregardingfiledtaxreturns. Name ___________________________________________________ Telephone_________________________________________________

E-MailAddress____________________________________________ StreetAddress_____________________________________________

Sample

SECTION H — APPLICANT DECLARATION AND SIGNATURE

This application will not be accepted if not signed by the applicant.

Iftheapplicantisasoleproprietorship,theproprietororownermustsign;ifapartnership,apartnermustsign;ifacorporation,anofficerofthecorporationauthorizedtosignonbehalfofthecorporationmustsign;ifalimitedliabilitycompany,anauthorizedmemberormanagermustsign;ifatrust,atrusteemustsign;ifapplicantisrepresentedbyanauthorizedagentforunemploymenttaxpurposes,theagentmaysign(attachexecutedpowerofattorney).THE SIGNATURE OF ANY OTHER PERSON WILL NOT BE ACCEPTED.

Pleasenotethatanyperson(includingemployees,corporatedirectors,corporateofficers,etc.)whoisrequiredtocollect,truthfullyaccountfor,andpayanytaxesandwillfullyfailstodososhallbeliableforpenaltiesundertheprovisionsofsection213.29,FloridaStatutes.Allinformationprovidedbytheapplicantisconfidentialasprovidedins.213.053,F.S.,andisnotsubjecttoFloridaPublicRecordsLaw(s.119.07,F.S.).

Under penalties of perjury, I attest that I am authorized to sign on behalf of the business entity identified herein, and also declare that I have read the information provided on this application and that the facts stated in it are true to the best of my knowledge and belief.

SIGNHERE ______________________________________________________________ Title _________________________________________Printname____________________________________________________________ Date _________________________________________

Amountenclosed:$__________________________ • $5 fee–Salestaxregistrationforbusiness/propertylocatedinFlorida. • $30 fee–Solidwasteregistrationfordrycleaners.

➢

✓ Completetheapplicationinitsentirety.

✓ MakesurethatyouhaveprovidedyourFEINorSSN.

✓ Signanddatetheapplication.

✓ Attachcheckormoneyorderforappropriateregistrationfeeamount. DO NOT SEND CASH.

✓ Mailto: FLORIDA DEPARTMENT OF REVENUE

5050 W TENNESSEE ST

TALLAHASSEE FL 32399-0100

You may also mail or deliver your application to any service center listed on the inside front cover.

USE THIS CHECKLIST TO ENSURE FAST PROCESSING OF YOUR APPLICATION.

DR-1 R. 09/09

Page 6

NAICS Code(s): FOR DOR USE ONLY

PM/Delivery Contract Object (MO)

B.P. No. Contract Object (LO)

UT Acct. No.. - Contract Object (other)

*Socialsecuritynumbers(SSNs)areusedbytheFloridaDepartmentofRevenueasuniqueidentifiersfortheadministrationofFlorida’staxes.SSNsobtainedfortaxadministrationpurposesareconfidentialundersections213.053and119.071,FloridaStatutes,andnotsubjecttodisclosureaspublicrecords.CollectionofyourSSNisauthorizedunderstateandfederallaw.VisitourInternetsiteatwww.myflorida.com/dorandselect“PrivacyNotice”formoreinformationregardingthestateandfederallawgoverningthecollection,use,orreleaseofSSNs,includingauthorizedexceptions.

Sample



Issuing Office


General Notes


Business Tax Registration(Municipality/Township, Vero Beach, 32963)

Sample

Sample

business license research & compliance package sample · goss development company prepared by:...

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