Home Caregiver Company Approved Signature Form

Home Caregiver Company Approved Signature Form
(To be completed by Home Caregiver Company/License Holder)
The following persons are authorized to sign affidavits on behalf of:
______________________________________________ , as of ___________ AHCA # _________
(Name of Florida State licensed Nursing/Health Care Agency)
Name (PRINT LEGIBLY)
(Date)
Title (PRINT LEGIBLY)
Signature
1.
2.
3.
4.
Changes to this information must be submitted in writing to Palm Beach County Division of Consumer Affairs
within 10 business days of change being made via email ([email protected]) or fax (561-712-6610).
_______________________________________
_____________________________________
(Signature of owner, partner or corporate officer)
(Printed name of owner, partner or corporate officer)
BUSINESS INFORMATION
Email Address
Website
Mailing Address
Phone
Physical Address (if different from above)
Phone
Fax
State of Florida, County of Palm Beach
Sworn and subscribed before me this _______day of ___________________, ______________.
Type of ID presented:
 Florida Driver’s License
___________________________________________
Signature of Notary Public, State of Florida
 Other _______________________
Notary stamp/seal