ADVERSE LICENSING ACTION HISTORY FORM

DEPARTMENT OF FINANCIAL SERVICES
Division of Funeral, Cemetery & Consumer Services
200 East Gaines Street
Tallahassee, FL 32399- 0361
ADVERSE LICENSING ACTION HISTORY FORM
This form is used in conjunction with various other main license application forms to provide details concerning
adverse license history. PRINT CLEARLY OR TYPE.
Section 1. IDENTIFYING INFORMATION
First name:
Middle Initial:
Last Name:
Or Establishment Name:
Email Address:
Birth Date (mm/dd/yyyy) if applicable:
/
/
General Instructions: “Type of License” – example, “funeral director.” Dates -- if you do not know the exact date, enter month
and year. “State where issued” – if issued in a foreign country, enter name of country. “Name of licensing authority” –
example, “Utah Embalmer’s Board.” Address of licensing authority – provide current full mailing address with zip code.
Section 2. DISCIPLINARY ACTION
If you have ever had any license to practice funeral directing, embalming, direct disposing, or any other regulated
profession revoked, suspended, fined, reprimanded, or otherwise disciplined, by any regulatory authority in
Florida or any other state or jurisdiction, enter the details in this Section. If you have more than one disciplinary
action to report, obtain additional copies of this form and put each disciplinary action on a separate copy of this
form, and attach all to your main application, when submitting same.
a. Type of
License:
b. State where
issued:
c. License
number:
d. Date issued
(Month/Year):
e. Currently in force? YES
NO
f. If NO, date terminated:
/
/
/
/
g. Name of licensing authority:
h. Address of licensing authority:
i. Date of adverse action:
/
/
j. Type of adverse action (check as many as are applicable):
Revocation
Restitution ($
Suspension (length:
)
)
Fine ($
Additional training required
)
Reprimand
Other (explain below):
k. If “Other” is checked above, explain here:
l. Have all sanctions been satisfied? YES
NO
(if NO, explain why in this block):
m. Explain what violation or misconduct the licensing authority asserted you had committed or were responsible for that
resulted in this adverse action:
n. Enter here any explanation or information which you desire the Board to consider regarding the disciplinary action disclosed
above:
Form DFS-N1-1715; Adverse Licensing Action History Form
(Rev. 07/12); 69K-1.001
Page 1 of 2
o. Do you have other disciplinary licensing actions to report? YES
NO
If yes, enter them on another copy of this form and attach all completed copies of this form to your application when submitting
same.
Section 3. PENDING INVESTIGATIONS
If you are currently to your knowledge under investigation by any regulatory or law enforcement authority in Florida or any
other state or jurisdiction in regard to alleged misconduct or incompetency in the performance of work as a funeral director,
embalmer, or direct disposer, complete this Section to the best of your knowledge and belief. If you do not have all requested
information, provide as much as you know.
a. Subject matter of pending investigation, to the extent you know:
b. Name of board, department, agency or office that is conducting the investigation:
c. What city and state is that agency or office located in?
d. Do you have other pending investigations to report? YES
NO
If yes, enter them on another copy of this form and attach all completed copies of this form to your application when submitting
same.
Section 4. DENIAL OF LICENSE APPLICATION
If you have ever had any application for license as a funeral director, embalmer, direct disposer, or other type of license in the
death care industry, denied for any reason by any regulatory authority in Florida or any other state or jurisdiction, complete
this Section.
a. Type of license applied for:
b. Name of Board or other agency which denied the application:
c. Address of the board or agency that denied the application (street, city, state, zip):
d. Month & year of denial of application:
e. Reason for denial:
f. Do you have other license denials to report? YES
NO
If yes, enter them on another copy of this form and attach all completed copies of this form to your application when submitting
same.
____________________________________
Applicant’s signature
___________________
Date
Section 5. FEIN OR SOCIAL SECURITY NUMBER
Enter Applicant’s FEIN or Social Security Number: Purpose and Use:
The collection of social security numbers on applications for licensure under Chapter 497 is expressly authorized by s. 497.141(2),
Florida Statutes. Social security numbers collected on applications will be used by the Department of Financial Services and the
Board of Funeral, Cemetery and Consumer Services as follows: identification of applicants; obtaining background checks on
applicants; obtaining information from authorities in other states; investigation of applicants and licensees concerning asserted
violations of applicable law or rules; enforcement of child support obligations. The social security number may also be used for any
other purpose required or authorized by federal or Florida Law.
Form DFS-N1-1715; Adverse Licensing Action History Form
(Rev. 07/12); 69K-1.001
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