Exam Application

EXAM APPLICATION FOR PUBLIC HEALTH APPLICATOR
Section 388, F.S., and Rule 5E-13.040 F.A.C.

Applicant must be 18 years of age or older to apply. Provide the details below. Fields marked with red asterisk are required. (Date Format: mm/dd/yyyy, Phone Format: 999-999-9999)

Examination Purpose

* Required New LicenseRenewalAdd a Category	If exists, License#:
Required

Applicant Information

First Name: *

Middle Name:

Last Name: *

Suffix:

Date of Birth: *

Place of Employment:

Title:

Florida Resident: * Required	Email: * Required Format: ex@email.com	Business Email: Format: ex@email.com
YesNo

Either home phone or cell phone is required. Format: 999-999-9999.

Home Phone:

Cell Phone:

Business Phone:

Fax Number:

Address Information
Home (Physical) Address: * Required	Line 2:	Home City: * Required	State: * Required	Zip Code: * Required

Mailing:* same as Home Required	Line 2:	Mailing City: * Required	State: * Required	Zip Code: * Required

Business Address: Required	Line 2:	Business City: Required	State: Required	Zip Code: Required

WILTON SIMPSON, Commissioner