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

* New LicenseRenewalAdd a Category	If exists, License#:

Applicant Information

First Name: *

Middle Name:

Last Name: *

Suffix:

Date of Birth: *

Place of Employment:

Title:

Florida Resident: *	Email: *	Business Email:
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: *	Line 2:	Home City: *	State: *	Zip Code: *

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

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

WILTON SIMPSON, Commissioner