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Have any professional licenses or commissions been revoked in the last 10 years? Have you been disciplined by a regulatory agency, including the Florida Bar, and including disciplinary action that is confidential or where the record has been sealed or expunged? Have you been convicted of a felony, had adjudication of guilt withheld, or are you on probation? If so, use this form to explain.

Be sure to explain in detail - otherwise there may be delays in processing your application.

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[NOTE: Your FULL legal name as it appears on your curent commission or what you entered for New App or Renewal App]


1120 Belcher Road South - Suite #1
Largo, FL 33771
(727) 578-4400 Office
(727) 577-4991 Fax

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