Form Dr-700012 - Application For Certification Of Communications Services Database
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2
3DR-700012
Application for Certification of
R. 10/13
Communications Services Database
TC
Rule 12A-19.100
Florida Administrative Code
Effective 01/14
Applications may be submitted online using the Department of Revenue’s PointMatch system located at:
https://pointmatch.state.fl.us
Please Read Instructions First
ü
Check one:
ü
Check one:
¨ Application for certification of database
¨ Provider of communications services
¨ Vendor (See Special Instructions for Vendors on page 3.)
¨ Application for recertification of database
¨ Both provider and vendor
(Check if the database is used both
internally and offered to other providers as part of a service.)
Section A - Business Information
Providers must enter this number. It is on the Certificate of Registration,
Form DR-700014. Not applicable for vendors.
Business Partner Number
Enter your Federal Employer Identification Number (FEIN).
Federal Employer
Identification Number
Business Name ______________________________________________________________________________________________________
Business Address ____________________________________________________________________________________________________
City ________________________________________________________ State ___________________________ ZIP ___________________
Business Mailing Address, if different from above ________________________________________________________________________
City ________________________________________________________ State ___________________________ ZIP ___________________
Section B – Contact Person
Applicant must designate a contact person responsible for providing access to all records, facilities, and processes that the Department determines are reasonably
necessary to review and make a determination regarding this application.
Name of Contact Person (please print) __________________________________ Telephone Number _____________________________
Address ____________________________________________________________________________________________________________
Fax Number _________________________________________________________ E-Mail Address ________________________________
Section C – Authorized Signature
Signature of person authorized to request certification on behalf of applicant.
Signature ____________________________________________________________ Date _________________________________________
Name (please print) ___________________________________________________ Title __________________________________________
Address, if different from above _______________________________________________________________________________________
Section D – Database Method of Submission (
ü
Check one) This section not applicable for vendors.
¨ Data file is uploaded with this application.
¨ Data file will be submitted through alternative means. (Please contact the Local Government Unit for assistance in submitting
your file.)
DOR Use Only
Mail application to:
Received by LGU ________________________________________
CST Database Certification
Local Government Unit
Date ____________________________________________________
Florida Department of Revenue
Application complete _____________________________________
PO Box 6530
Tallahassee FL 32314-6530
Date ____________________________________________________
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