Dbpr Form Abt-6027 - Examination Application (Page 2 of 2) in pdf

Dbpr Form Abt-6027 - Examination Application Page 2

SECTION 2 - AFFIDAVIT OF APPLICANT

NOTARIZATION REQUIRED

Business Name (D/B/A)

"I, the undersigned individual, or if a corporation for itself, its officers and directors, hereby swear or affirm

that I am duly authorized to make the above and foregoing application and, as such, I hereby acknowledge

that the time frame for the activation of this license is understood as indicated hereon. I swear under oath or

affirmation under penalty of perjury as provided for in Sections 559.791, 562.45, and 837.06, Florida

Statutes that the foregoing information is true and correct."

STATE OF___________________

_________________________________________________

APPLICANT (Signature must be notarized)

COUNTY OF_________________

_________________________________________________

APPLICANT (Signature must be notarized)

The foregoing was ( ) Sworn to and Subscribed OR ( ) Acknowledged Before me this _______Day

of______________, 20_______, By ___________________________________ who is ( ) personally

known to me OR ( ) who produced ______________________________________________as

identification.

________________________________________________ Commission Expires: ___________________

Notary Public

FOR DIVISION USE ONLY – DO NOT WRITE BELOW THIS LINE

District Office Received Date Stamp

District Office Accepted Date Stamp

Dbpr Form Abt-6027 - Examination Application Page 2