Criminal Self-Reporting Document Template - Department Of Business And Professional Regulation (Dbpr)

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CRIMINAL SELF-REPORTING DOCUMENT
Department of Business and Professional Regulation (DBPR)
Note: Effective October 1, 2009, Section 455.227(1)(t), Florida Statutes, requires that a licensee must report to the
board or, if there is no board, to the department within 30 days after a licensee is convicted or found guilty of, or entered
a plea of nolo contendere (no contest) or guilty to, regardless of adjudication, a crime in any jurisdiction. If you
previously reported a criminal conviction or plea to DBPR, you do not need to report it again.
1. Last Name (Surname), First Name, Middle Name
2. Date of Birth
3. Address
4. City
5. State
6. Zip
7. Telephone (Home)
8. Telephone (Cell)
9. E-mail
10. Profession(s) – list all DBPR licenses:
11. Professional license number(s) – list all DBPR license numbers:
a.
a.
b.
b.
c.
c.
12. Have you pled guilty or nolo contendere (no
13. Have you been convicted or found guilty in any jurisdiction,
contest) to any crime in any jurisdiction?
regardless of adjudication, of any crime in any jurisdiction? Please
Please check one:
Yes
No
check one:
Yes
No
14. For each crime to which you pled guilty or nolo contendere (no contest), or for which you were convicted or found
guilty in any jurisdiction, regardless of adjudication, please state the following:
a. Name of court:
b. Address of court:
c. Case number:
d. Date of plea or conviction:
e. Name of crime:
a. Name of court:
b. Address of court:
c. Case number:
d. Date of plea or conviction:
e. Name of crime:
a. Name of court:
b. Address of court:
c. Case number:
d. Date of plea or conviction:
e. Name of crime:
Note: If you have more than three convictions to report, please attach an additional sheet including the above information.
Date:
Signature of Licensee:
Mailing Address: CPA
Mailing Address: Real Estate
Mailing Address: All Others
Division of Certified Public Accounting
Division of Real Estate
Division of Regulation
th
240 NW 76
Dr, Suite A
400 W. Robinson St., N801
1940 N. Monroe St.
Gainesville, FL 32607
Orlando, FL 32801
Tallahassee, FL 32399-0782
DBPR Form No. TBD
Page 1 of 1
Criminal Self Reporting Document

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