Request for Disciplinary and Licensure Documents

Fees and Charges

• $.00 for 50 pages or less
• 
  
• $.15 per page for the total number of pages if the number exceeds 50 pages (e.g., if the documents equal 52 pages, requestor is charged for 52 pages, not 2 pages)
• 
  
• Microfiche - $.62 per page for the total number of pages if the number exceeds 15 pages (e.g., if documents equal 16 pages, requestor is charged for 16 pages, not 1 page)
• 
  
• Certification of documents $25.00 each
• 
  
• Research time is charged when in excess of 30 minutes and is based on the salary level of the lowest paid employee able to perform the research.
• 
  

  ---

  
  I would like certified copies. ($25.00 fee - written statement on a public record attesting to the record's genuineness or that it is a true and correct copy)
  Yes
  No
  
  Licensee First Name or Business Name:
  
  
  Licensee Last Name:
  
  
  Licensee License Number:
  
  
  Licensee Profession:
  
  
  Document Type (check all that apply)
  Disciplinary Documents
  Complete Licensure File
  Application Only
  Declaratory Statement
  Both Licensure File and Discipinary Documents
  other:
  
  Additional identifying information (address, school, etc.) or special instructions to processor. Limit of 4 lines.
  
  
  

  ---

  Please enter requestor information below:
  
  Requestor Name:
  
  
  Company:
  
  
  Email:
  
  
  Telephone:
  
  
  Extension:
  
  
  Fax:
  
  
  Street Number:
  
  
  Street Name:
  
  
  Street Address Line 2:
  
  
  City:
  
  
  State:
  
  
  Zip Code
  
  
  (Note:Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.)

  ---

  
   

  Please mail documents to:
   

  
  Use Requestor Address?
  Yes
  No, please use mailing address below.
  
  Contact Name:
  
  
  Company:
  
  
  Email:
  
  
  Telephone:
  
  
  Street Number:
  
  
  Street Name:
  
  
  Address Line 2:
  
  
  City:
  
  
  State:
  
  
  Zip: