Sample. Business License Research & Compliance Package. Business License Portfolio Management Business License Filing & Renewal Services

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1 Business License Research & Compliance Package Prepared for: GOSS DEVELOPMENT COMPANY Prepared by: Corporation Service Company Prepared on: March 10, 2010 Business License Portfolio Management Business License Filing & Renewal Services License Verification Audit & Gap Analysis Fully-Managed Outsourcing

2 Business License Research & Compliance Package Principal Business Address Contact Information 2000 Beachside Drive RYAN PETER Vero Beach,FL,32063 GOSS DEVELOPMENT COMPANY County: Your Request BLCP Location(s) Where You Conduct Business FL,Vero Beach Business Activity/Industry Segment Order ID Residential Construction Number of Employees 1 Products/Services Provided Estate Homes This report contains business license and tax application(s) that have been identified on your behalf. Each application is preceded with a cover sheet containing the licensing authority's contact information (name, address, telephone number, etc.) as well as instructions on how to file your application. State Level (FL): - Application for Initial Issuance of Licensure for Certified Contractors - Application to Collect And/Or Report Tax Local Level (Vero Beach) - Business Tax Registration

3 Business License Research & Compliance Package Package Scope This report sets forth the license and permit requirements we have identified as being relevant to Residential Construction. These requirements are based on details provided in connection with location and business activity. The business address provided is within the incorporated city of Vero Beach, County of in the State of FL. Overview of Licenses and Permits Federal Level: State Level (FL): The following license and/or permit requirements may be relevant to Residential Construction at the State level: - Application for Initial Issuance of Licensure for Certified Contractors - Application to Collect And/Or Report Tax County Level () We have not identified any license and/or permit requirements that are relevant to Residential Construction at the County level. Local Level (Vero Beach) The following license and/or permit requirements may be relevant to Residential Construction at the Local level: - Business Tax Registration If you are interested in having CSC assist you with form preparation, filing or any of the services listed below, please contact a CSC Business License Specialist at (800) x5077 or businesslicenses@cscinfo.com. - Business License Prep & Filing - Fictitious Name (DBA) - License Outsourcing Services - Business License Renewal Service - License Portfolio Management - Inc & LLC Formations - Federal Tax Identification (EIN) - Audit & Gap Analysis - Qualifications - License Verification

4 Business License Research & Compliance Package Application for Initial Issuance of Licensure for Certified Contractors (State, FL) If you have questions regarding this application, please contact the issuing authority using the information provided below. Issuing Office Mailing Address Mail the application to the mailing address provided below, unless otherwise noted on the form. General tes Information pertaining to this form

5 INFORMATION REGARDING COMPLETION OF INITIAL ISSUANCE OF LICENSURE FOR CERTIFIED CONTRACTORS DBPR CILB 4359 Application begins on page 5. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at In filing an application, be certain that the application is completely filled out, that all questions are answered truthfully and that all the information requested is provided. Please type or print in ink. Applicants are cautioned to read questions thoroughly. A false answer concerning financial or background information will subject the applicant to denial or subsequent disciplinary action against the license. QUALIFICATIONS: In order to become a licensed certified contractor in the State of Florida, an applicant must meet educational requirements, pass the state certification examination, obtain workers compensation and general liability insurance coverage, and demonstrate financial responsibility. A certified contractor means any contractor who possesses a certificate of competency issued by the department and who shall be allowed to contract in any jurisdiction in the state without being required to fulfill the competency requirements of that jurisdiction. Please note that if you currently hold a license and you intend to operate the proposed license under a separate business organization, you must also complete the Qualifying Additional Business Organization Application Package. This applies even if you intend to qualify a business organization with one license and operate as an individual with the other license. This applies even if one business is operating under a Division I license and the other is operating under a Division II license. However, you do not have to pay the fee listed in the Qualifying Additional Business Organization Application. ELECTRONIC FINGERPRINTING: Beginning vember 1, 2007, all applications for initial licensure or changes of status will be required to have a criminal background check performed by the Florida Department of Law Enforcement and Federal Bureau of Investigation. You are responsible for ensuring that your fingerprints have been scanned by the Department s vendor, Pearson VUE, prior to submitting your application. The fingerprint results are only valid for a period of six months from the date you submitted the fingerprints to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. Electronic fingerprinting is located at various convenient sites throughout Florida ( Reservations and payment can be made by visiting the Pearson VUE reservation website at (and selecting Digital Fingerprinting Services ) or by calling Pearson VUE at You must pay a fee of $57.25 to Pearson VUE for the processing of your electronic fingerprints. This cost is in addition to the application fees listed on this application package. If you are located outside of the state of Florida, or if you have any questions regarding the electronic fingerprinting process, please visit COMPUTER-BASED BUSINESS AND FINANCE EXAMINATION/FEE CHANGE: As of January 1, 2009, the business and finance portion of the state certification examination will be computer-based. As a result, the department now collects the examination administration fee at the time of examination. Please refer to the instructions on page 2 for the revised initial licensure fee schedule October Page 1 of 20 CILB: Initial Licensure Certified Contractor

6 APPLICATION CHECKLIST: Select the appropriate Transaction below which applies to your situation and follow the steps identified in the corresponding Application Checklist box. TRANSACTION APPLICATION CHECKLIST FEES: IF ALL EXAM PARTS WERE PASSED PRIOR TO JANUARY 1, 2009: Applying for initial licensure from MAY 1 st of an EVEN YEAR through AUGUST 31 st of an ODD YEAR $409 OR Applying for initial licensure from SEPTEMBER 1 st of an ODD YEAR through APRIL 30 th of an EVEN YEAR $309 Initial Issuance of Licensure for CERTIFIED Contractors FOR INDIVIDUAL ONLY Make check payable to the Department of Business and Professional Regulation. IF ANY EXAM PART WAS PASSED AFTER JANUARY 1, 2009: Applying for initial licensure from MAY 1 st of an EVEN YEAR through AUGUST 31 st of an ODD YEAR $249 OR Applying for initial licensure from SEPTEMBER 1 st of an ODD YEAR through APRIL 30 th of an EVEN YEAR $149 FORMS: DBPR CILB 4359 Initial Issuance of Licensure for Certified Contractors and have work experience affidavit notarized. DBPR 0010 Master Individual Application DBPR CILB 4370 CILB Financial Statement (For active status only.) DBPR 0050 and DBPR 0060, as applicable, if you responded yes to any of the Financial Responsibility Questions or any questions on DBPR 0010 Master Individual Application. Be advised that affirmative responses may require that your application be presented to the Construction Industry Licensing Board for review. SUPPORTING DOCUMENTATION: Credit report on applicant from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state and federal levels. t every credit reporting agency includes this information. For a list of agencies, visit (For active status only.) Make sure you have filed your electronic fingerprints with Pearson VUE. Please note that the fingerprint results are only valid for a period of six months from the date the fingerprints were submitted to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. (See page 1 of this package for additional information.) Proof of satisfaction of liens, judgments and discharge of bankruptcy, if applicable. (For active status only.) Bank verification letter. (Required if you include cash on your financial statement for active status only.) Listing of machinery and equipment. (For active status only.) Proof of CILB grade report indicating overall status as passed for all applicable parts of examination. Grade report must be no older than three years. Swimming Pool Specialty License applicants - provide practical examiner grade report and CILB-approved education provider certificates indicating completion of one hour each of workplace safety, business practices and workers compensation courses October Page 2 of 20 CILB: Initial Licensure Certified Contractor

7 TRANSACTION Initial Issuance of Licensure for CERTIFIED Contractor WHO IS QUALIFYING A BUSINESS (ACTIVE STATUS ONLY.) Make check payable to the Department of Business and Professional Regulation. APPLICATION CHECKLIST FEES: IF ALL EXAM PARTS WERE PASSED PRIOR TO JANUARY 1, 2009: Applying for initial licensure from MAY 1 st of an EVEN YEAR through AUGUST 31 st of an ODD YEAR $409 OR Applying for initial licensure from SEPTEMBER 1 st of an ODD YEAR through APRIL 30 th of an EVEN YEAR $309 IF ANY EXAM PART WAS PASSED AFTER JANUARY 1, 2009: Applying for initial licensure from MAY 1 st of an EVEN YEAR through AUGUST 31 st of an ODD YEAR $249 OR Applying for initial licensure from SEPTEMBER 1 st of an ODD YEAR through APRIL 30 th of an EVEN YEAR $149 FORMS: DBPR CILB 4359 Initial Issuance of Licensure for Certified Contractors and have work experience affidavit notarized. DBPR 0010 Master Individual Application DBPR CILB 4370 CILB Financial Statement on BUSINESS DBPR CILB 4357 Construction Business Information Form DBPR 0050 and DBPR 0060, as applicable, if you responded yes to any of the Financial Responsibility Questions on DBPR 0010 Master Individual Application or DBPR CILB 4357 Construction Business Information Form. Be advised that affirmative responses may require that your application be presented to the Construction Industry Licensing Board for review. (continued on next page) 2009 October Page 3 of 20 CILB: Initial Licensure Certified Contractor

8 TRANSACTION APPLICATION CHECKLIST SUPPORTING DOCUMENTATION: Credit reports on applicant and business from a nationally recognized credit reporting agency, which includes a public records statement that records have been checked at local, state and federal levels. t every credit reporting agency includes this information. For a list of agencies, visit Make sure you have filed your electronic fingerprints with Pearson VUE. Please note that the fingerprint results are only valid for a period of six months from the date the fingerprints were submitted to the vendor. Please allow time for the initial processing of your application and any time required to address application deficiencies that may arise during the review of your application. (See page 1 of this package for additional information.) Proof of satisfaction of liens, judgments and discharge of bankruptcy, if applicable. Bank verification letter. (Required if you include cash on your financial statement.) Listing of machinery and equipment. Proof that property, buildings, vehicles or life insurance is in the name of the business if listed on the financial statement. Proof of CILB grade report indicating overall status as passed for all applicable parts of examination. Grade report must be no older than three years. Swimming Pool Specialty License applicants - provide practical examiner grade report and CILB-approved education provider certificates indicating completion of one hour each of workplace safety, business practices and worker's compensation courses. NOTE: If the Financially Responsible Officer is not the primary qualifier for the business, the officer will need to complete DBPR CILB 4366 Financially Responsible Officer form, pay a $200 fee and submit supporting documentation as required. Please send your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation 1940 rth Monroe Street Tallahassee, FL October Page 4 of 20 CILB: Initial Licensure Certified Contractor

9 DBPR CILB 4359 Initial Issuance of Licensure for CERTIFIED Contractors page 1 of 5 NOTE This form must be submitted as part of an entire application packet. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at APPLICANT INFORMATION Last Name First Middle Title Suffix Social Security Number* Telephone Number CHECK ONLY ONE LICENSE CATEGORY For definitions and information on license categories, go to Class A Air- Conditioning Class B Air- Conditioning Building Roofing Plumbing General Mechanical Specialty: Marine Commercial Pool/Spa Residential Pool/Spa Swimming Pool/Spa Servicing Residential Sheet Metal Specialty: Solar Water Heating Underground Utility and Excavation Solar Specialty: Dry Wall Specialty: Structure Specialty: Glass & Glazing Specialty: Gas Line Pollutant Storage Systems Specialty: Swimming Pool Layout Specialty: Swimming Pool Structural Specialty: Swimming Pool Excavation Specialty: Swimming Pool Trim Specialty: Swimming Pool Decking Specialty: Swimming Pool Piping Specialty: Swimming Pool Finishes CHECK APPLICABLE TRANSACTION One box must be checked in each section below Active Individual DO NOT complete pages Inactive Inactive status does not apply for businesses. FOR INACTIVE STATUS ONLY, DO NOT COMPLETE THE FINANCIAL STATEMENT FORM AND DO NOT PROVIDE CREDIT REPORTS OR BANK VERIFICATION LETTER. Business Complete all pages. Name of Business: INSURANCE FOR ACTIVE STATUS ONLY Have you obtained public liability and property damage insurance in the amounts determined by rule of the Construction Industry Licensing Board? Minimum amounts required for General Liability Insurance: General and Building Contractors - $300,000 bodily injury; $50,000 property damage All other Categories - $100,000 bodily injury; $25,000 property damage Have you obtained workers compensation insurance or filed for an exemption with the Division of Workers Compensation, and if not, do you attest that you will obtain an exemption within 30 days after your license is issued? *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections (9), , and , Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec October Page 5 of 20 CILB: Initial Licensure Certified Contractor

10 DBPR CILB 4359 Initial Issuance of Licensure for CERTIFIED Contractors page 2 of 5 Please give the details of your work experience history. Please refer to Section , Florida Statutes, and Rule 61G , Florida Administrative Code. DESCRIBE EXPERIENCE AND WORK PERFORMED EXPERIENCE HISTORY SUBMIT ADDITIONAL SHEETS IF NECESSARY LIST JOBS where the described Name, Address Experience was gained (list number & Phone of stories if applying for GENERAL) Number of and List the company and/or Employer or contractors that supervised your Name of work Company TIME SPENT on projects listed FROM/TO 2009 October Page 6 of 20 CILB: Initial Licensure Certified Contractor

11 DBPR CILB 4359 Initial Issuance of Licensure for CERTIFIED Contractors page 3 of 5 QUALIFICATION FOR LICENSURE CHECK ONLY ONE BOX A person shall qualify for certification licensure by meeting one of the following requirements: 1. Four year construction-related degree from an accredited college (equivalent to three years experience) and one year proven experience applicable to the category for which you are applying 2. One year of experience as a foreman and not less than 3 years of credits for any accredited college-level courses 3. One year experience as a workman, one year proven experience as a foreman and two years of credits for any accredited college-level courses 4. Two years experience as a workman, one year experience as a foreman and one year of credits for any accredited college-level courses 5. Four years experience as a workman or foreman of which at least one year must have been as a foreman 6. Holding an active certified Florida contractor s license. If checked, please fill in: License # Date issued If item #6 is selected: This option only applies to Certified Building, Residential, Air- Conditioning and Swimming Pool contractors as provided in Section (2)(c)4-6, Florida Statutes October Page 7 of 20 CILB: Initial Licensure Certified Contractor

12 DBPR CILB 4359 Initial Issuance of Licensure for CERTIFIED Contractors page 4 of 5 TO BE COMPLETED BY PERSON VERIFYING EXPERIENCE AND NOTARY PUBLIC All years of experience necessary for qualification must be verified. Applicants may submit more than one affidavit. I certify that I have direct knowledge of the work (PRINT NAME OF PERSON VERIFYING EXPERIENCE) experience of and that he or she meets the (PRINT APPLICANT'S NAME ) requirements for as set forth in Section (2)c, (TYPE OF LICENSE APPLYING FOR) Florida Statutes, and Rule 61G , Florida Administrative Code. I further understand my license can be subject to discipline if the information given and attested to by me is found to be misleading and fraudulent. Name of individual verifying experience: Verifier s License Number (attach copy of license): Verifier s Employer (DBA Name): Verifier s Employer (DBA) Address: Phone Number: Describe in detail the applicant's duties, dates of employment, and employer, including any hands on/supervisory responsibilities: 2009 October Page 8 of 20 CILB: Initial Licensure Certified Contractor

13 DBPR CILB 4359 Initial Issuance of Licensure for CERTIFIED Contractors page 5 of 5 Applicant s experience (continued): Applicant s Years of Supervisory Experience: From To (DATE) (DATE) tarized Signature of Person Verifying Experience: Date: I may be reached by phone for comment, if necessary, at the telephone number shown below during business hours. REQUIRED Phone Number: STATE OF COUNTY OF Sworn to (or affirmed) and subscribed before me this day of, 20, by (Name of person making statement) (Signature of tary Public-State of ) (tary Seal) (Name of tary; typed, printed, or stamped) Personally known OR produced identification Type of identification produced 2009 October Page 9 of 20 CILB: Initial Licensure Certified Contractor

14 DBPR 0010 Master Individual Application page 1 of 3 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION Social Security Number* PERSONAL INFORMATION Last Name First Middle Title Suffix Birth Date (MM/DD/YYYY) Race/Ethnicity (check only one): Black or African American White or Caucasian Street Address or P.O. Box Gender Male Female Asian or Pacific Islander Spanish, Hispanic or Latino MAILING ADDRESS Native American or Alaskan Native Other City State Zip Code (+4 optional) County (if Florida address) Country CONTACT INFORMATION Primary Phone Number Primary Address RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS) Street Address City State Zip Code (+4 optional) County (if Florida address) Country Business/Firm Name Street Address BUSINESS LOCATION ADDRESS City State Zip Code (+4 optional) County (if Florida address) Country ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number Alternate Address *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections (9), , and , Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec October Page 10 of 20 CILB: Initial Licensure Certified Contractor

15 DBPR 0010 Master Individual Application page 2 of 3 PRIOR LICENSE INFORMATION If you currently or previously have held a business or professional license/registration in Florida or elsewhere, please list them below: 1. License/Registration Type State Date (From) Date (To) License Number Name Used 2. License/Registration Type State Date (From) Date (To) License Number Name Used 3. License/Registration Type State Date (From) Date (To) License Number Name Used 1. (If yes, please complete form ) 2. (If yes, please complete form ) 3. (If yes, please complete form ) 4. (If yes, please complete form ) BACKGROUND INFORMATION Have you ever been convicted of a crime, found guilty, or entered a plea of guilty or nolo contendere (no contest) to, even if you received a withhold of adjudication? This question applies to any violation of the laws of any municipality, county, state or nation, including felony, misdemeanor and traffic offenses (but not parking, speeding, inspection, or traffic signal violations), without regard to whether you were placed on probation, had adjudication withheld, were paroled, or pardoned. If you intend to answer NO because you believe those records have been expunged or sealed by court order pursuant to Section , Florida Statutes, or applicable law of another state, you are responsible for verifying the expungement or sealing prior to answering "NO." YOUR ANSWER TO THIS QUESTION WILL BE CHECKED AGAINST LOCAL, STATE AND FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE DEPARTMENT. Has any judgment or decree of a court been entered against you in this or any other state, province, district, territory, possession or nation, in which you were charged in the petition, complaint, declaration, answer, counterclaim, or other pleading with any fraudulent or dishonest dealing, or is there any such case or investigation pending? Have you ever had an application for registration, certification, or licensure in Florida or in any other jurisdiction denied, or is there now pending a proceeding or investigation to deny such an application? Has any license, registration or permit to practice any regulated profession, occupation, vocation, or business been revoked, annulled, suspended, relinquished, surrendered, or withdrawn in Florida or in any other jurisdiction, or is any such proceeding or investigation now pending? If you answered YES to questions 1 4 above, please provide the full details of any criminal conviction, lawsuit or judgment, or administrative action including the nature of any charges, dates, outcomes, sentences, and/or conditions imposed; the dates, name and location of the court and/or jurisdiction in which any proceedings were held or are pending; and the designation and/or license number for any actions against a license or licensure application. Please utilize form for your responses to questions 1 and 2, and form for your responses to questions 3 and 4. If you have more than seven offenses to document on form , attach additional copies of form as necessary. PRIOR NAME INFORMATION Have you used, been known as, or called by another name (example - maiden name, pseudonym, nickname) or alias other than the name signed to the application? If your answer is yes, state name or names used below: Last Name First Middle Title Suffix Last Name First Middle Title Suffix Last Name First Middle Title Suffix 2009 October Page 11 of 20 CILB: Initial Licensure Certified Contractor

16 DBPR 0010 Master Individual Application page 3 of 3 ATTEST STATEMENT I have read the questions in this application and have answered them completely and truthfully to the best of my knowledge. I have successfully completed the education, if any, required for the level of licensure, registration, or certification sought. I have the amount of experience required, if any, for the level of licensure, registration, or certification sought. I pledge to comply with the applicable standards of practice upon licensure, registration, or certification. I understand the types of misconduct for which disciplinary proceedings may be initiated. Giving knowingly misleading statements or knowing misrepresentation when applying for a license constitutes a felony of the third degree and may result in licensure denial or revocation. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true. Signature: Print Name: Social Security Number: 2009 October Page 12 of 20 CILB: Initial Licensure Certified Contractor

17 DBPR CILB 4370 CILB Financial Statement page 1 of 2 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 rth Monroe Street Tallahassee, FL NOTE This form must be submitted as part of an entire application packet. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at APPLICANT INFORMATION Last Name First Middle Title Suffix Social Security Number* Telephone Number APPLYING FOR LICENSURE AS (Select Only One): Individual Financial Statement reflects financial Sole Proprietor Financial Statement condition of APPLICANT reflects financial condition of COMPANY OR OWNER Corporation Financial Statement reflects financial Partnership Financial Statement reflects condition of CORPORATION financial condition of PARTNERSHIP As part of the Financial Statement, you must provide the following supporting documentation unless you are submitting an audited CPA prepared financial statement: If you are showing inventory, machinery, fixtures and equipment as part of your total assets, you must attach a listing of these items and monetary value of each to this form. If you include cash in bank as part of your financial statement, you must submit a bank verification letter that indicates the name on the account and the current account balance. The bank verification letter may be no older than three months. If you are providing a business financial statement, you must ensure that your bank account is in the legal name of the business entity. IF YOU ARE APPLYING TO QUALIFY A CORPORATION, PARTNERSHIP, TRUST OR OTHER LEGAL ENTITY, you must also include documented proof that any property, buildings, vehicles, or life insurance is in the name of the corporation, partnership, trust, or legal entity unless you are submitting an audited CPA prepared financial statement. *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections (9), , and , Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec October Page 13 of 20 CILB: Initial Licensure Certified Contractor

18 DBPR CILB 4370 CILB Financial Statement page 2 of 2 FINANCIAL STATEMENT Statement of Financial Condition Of: (Individual Name or Name of Business Being Qualified, as appropriate.) Date of Financial Statement: ASSETS (Omit Cents) SSN/FEID Number: LIABILITIES (Omit Cents) 1. Cash in Bank Refer to statement on previous page regarding verification of cash in bank. 2. Accounts and tes Receivable $ 14. Accounts Payable $ $ 15. tes Payable to Banks and Others (i.e., vehicles/ equipment/lines of credit, etc.) 3. Inventory, i.e., supplies $ 16. Mortgages and Bonds $ Payable 4. US Government Securities $ 17. Unpaid Taxes $ 5. Other Current Assets, i.e., vehicles (itemize) 6. Real Estate $ 7. Buildings-Net $ (after depreciation) 8. Machinery, Fixtures & $ Equipment (after depreciation) 9. Leasehold Improvements- $ Net (after amortization) 10. Cash Surrender Value of $ Life Insurance 11. Stock & Bonds $ 12. Other Assets (itemize) $ 18. Wages & Interest $ $ 19. Other Liabilities (if corporation) $ $ $ $ $ 13. Total Assets (add items 1 thru 12 above) $ 20. Total Liabilities (add items 14 thru 19 above) $ 21. Net Worth (Subtract Item 20 from Item 13.) $ TOTAL from Line 13 $ TOTAL LIABILITIES/NET WORTH Add lines 20 and 21 $ PLEASE NOTE THAT THE TOTAL ASSETS COLUMN AND TOTAL LIABILITIES/NET WORTH COLUMN MUST EQUAL THE SAME AMOUNT October Page 14 of 20 CILB: Initial Licensure Certified Contractor

19 DBPR CILB 4357 Construction Business Information Form page 1 of 4 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 1940 rth Monroe Street Tallahassee, FL This application must be submitted with a licensed contractor s change of status application or a contractor s initial licensure application. If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at This application is NOT required if you are applying for an individual license. APPLICANT INFORMATION Last Name First Middle Title Suffix Social Security Number* License Number Certified Registered Attach copy of Local Competency Card. City/County of Issuance: Telephone Number CHECK APPLICABLE TRANSACTIONS Check only one box in each section below Qualify a New Business Construction Business Change of Status: From Primary to Secondary Qualifier From Secondary to Primary Qualifier Add Additional Qualifier Change Officer(s) Change from One Qualifier to Another Amended Corporate Name Change *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections (9), , and , Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec October Page 15 of 20 CILB: Initial Licensure Certified Contractor

20 DBPR CILB 4357 Construction Business Information Form page 2 of 4 Corporate Name BUSINESS TO BE QUALIFIED INFORMATION Doing Business As (DBA) Federal Employer ID Number (FEID) Business Longer Qualified Ownership: Sole Proprietorship Corporation Partnership Street Address or P.O. Box MAILING ADDRESS City State Zip Code County (if Florida address) Country Contact Name Primary Phone Number CONTACT INFORMATION Primary Address RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS) Street Address City State Zip Code County (if Florida address) Street Address Country BUSINESS LOCATION ADDRESS City State Zip Code County (if Florida address) Country ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number Alternate Address INSURANCE Have you obtained public liability and property damage insurance in the amounts determined by rule of the Construction Industry Licensing Board? Minimum amounts required for General Liability Insurance: General and Building Contractors - $300,000 bodily injury; $50,000 property damage All other Categories - $100,000 bodily injury; $25,000 property damage Have you obtained workers compensation insurance or filed for an exemption with the Division of Workers Compensation, and if not, do you attest that you will obtain an exemption within 30 days after your license is issued? 2009 October Page 16 of 20 CILB: Initial Licensure Certified Contractor

21 DBPR CILB 4357 Construction Business Information Form page 3 of 4 PRIMARY QUALIFYING AGENT / FINANCIALLY RESPONSIBLE OFFICER Name of person legally appointed as the qualifier to act for the business organization in all matters connected with its contracting business, and who has been given authority to supervise all construction work performed by the business (this must be the applicant or a licensed contractor): Primary Qualifying Agent Name License Number (if applicable) Does the primary qualifying agent also have final approval authority on all business matters, including contracts, specifications, checks, drafts, or payments, regardless of the form of payment, made by the entity? If no, you must appoint a Financially Responsible Officer by completing form DBPR CILB 4366 Financially Responsible Officer Application Package and returning it to our office with your application. This will alleviate the licensed qualifier s financial responsibility, but the qualifier will still be responsible for all construction-related matters. Name of Financially Responsible Officer (if different than primary qualifier): SECONDARY QUALIFYING AGENT (OPTIONAL) Name of person legally appointed as a secondary qualifier and is responsible only for the supervision of fieldwork at sites where his or her license was used to obtain the building permit and any other work for which he or she accepts responsibility (this must be the applicant or a licensed contractor): Secondary Qualifying Agent Name License Number (if applicable) A secondary qualifying agent is not responsible for the supervision of financial matters. ORGANIZATIONAL RELATIONSHIPS Do you qualify any business other than the business you are applying to qualify? (If yes, complete DBPR CILB 4353 Qualify Additional Business Organization form) Name of Business: BUSINESS OWNERSHIP List below the business owners and percentage of ownership for each. TOTAL MUST EQUAL 100%. Social Security Name of Owner & Title Address. * % of Ownership 2009 October Page 17 of 20 CILB: Initial Licensure Certified Contractor

22 DBPR CILB 4357 Construction Business Information Form page 4 of 4 FINANCIAL RESPONSIBILITY/BACKGROUND QUESTIONS NOTE: If you answer to any of the questions below, you must provide an explanation on DBPR 0060 General Explanatory Description form and attach legal documentation (i.e., satisfaction of lien, judgment, payment schedule, etc.) The following persons must answer the financial responsibility questionnaire: Qualifying Agent/Applicant All Business Officers (President, Secretary, etc.) Indicate your response by circling "" or "" on the grid provided below. Have you, or a partnership in which you were a partner, or an authorized representative, or a corporation in which you were an officer or an authorized representative ever: 1. Undertaken construction contracts or work that a third party, such as a bonding or surety company, completed or made financial settlements? 2. Had claims or lawsuits filed for unpaid past-due bills by your creditors as a result of construction operations? 3. Undertaken construction contracts or works which resulted in liens, suits or judgments being filed? (If yes, you must attach a copy of the tice of Lien and any payment agreement, satisfaction, Release of Lien or other proof of payment.) 4. Had a lien filed against you by the U.S. Internal Revenue Service or Florida Corporate Tax Division? 5. Made an assignment of assets in settlement of construction obligations for less than the debts outstanding? 6. Been charged with or convicted of acting as a contractor without a license, or, if licensed as a contractor in this or any other state, been subject to any disciplinary action by a state, county, or municipality? (If yes, you must attach a copy of any state, county, municipal or out-of-state disciplinary order or judgment.) 7. Filed for or been discharged in bankruptcy within the past five years? (If "yes", you must attach a copy of the Discharge Order, Order Confirming Plan, or if a Corporate Chapter 7 case, a copy of the tice of Commencement.) 8. Been convicted or found guilty of or entered a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction? Indicate your response by circling or Question Number: Applicant Print Name Officer Print Name Officer Print Name Officer Print Name Officer Print Name October Page 18 of 20 CILB: Initial Licensure Certified Contractor

23 DBPR 0050 Explanatory Information for Background Questions page 1 of 1 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION NOTE This form must be submitted as part of an application packet. PERSONAL INFORMATION Last Name First Middle Title Suffix Identify question number on form DBPR 0010 this explanation pertains to: Offense County Penalty/Disposition Date of Offense (MM/DD/YYYY) Description Offense County Penalty/Disposition Date of Offense (MM/DD/YYYY) Description EXPLANATION State EXPLANATION Have all sanctions been satisfied? State Have all sanctions been satisfied? Attach additional sheets as necessary 2009 October Page 19 of 20 CILB: Initial Licensure Certified Contractor

24 DBPR 0060 General Explanatory Description page 1 of 1 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION NOTE This form must be submitted as part of an application packet. APPLICANT INFORMATION Last Name First Middle Title Suffix EXPLANATION 2009 October Page 20 of 20 CILB: Initial Licensure Certified Contractor

25 Business License Research & Compliance Package Application to Collect And/Or Report Tax (State, FL) If you have questions regarding this application, please contact the issuing authority using the information provided below. Issuing Office Mailing Address Mail the application to the mailing address provided below, unless otherwise noted on the form. General tes Information pertaining to this form

26 APPLICATION TO COLLECT AND/OR REPORT TAX IN FLORIDA Who must apply? DR-1 R. 09/09 You may be required to register to collect, accrue, and remit the taxes or fees listed below if you are engaged in any of the activities listed beneath each tax or fee. Complete Sections A, B, and H Sales Tax Pay $5 fee (in-state only)* Sales, leases, or licenses to use certain property or goods (tangible personal property). Sales and rentals/admissions, amusement machine receipts, or vending machine receipts for all taxable items. Repair or alteration of tangible personal property. Leases or licenses to use commercial real property (includes management companies). Rental of transient (six months or less) living or sleeping accommodations (includes management companies). A local tourist development tax (bed tax) may also apply. Contact the taxing authority in the county where the property is located. Sales or rental of self-propelled, powerdrawn, or power-driven farm equipment. Sales of electric power or energy. Sales of prepaid telephone calling cards. Sales of commercial pest control services, nonresidential building cleaning services, commercial/residential burglary and security services, or detective services. Sales of secondhand goods. A secondhand dealer registration (Form DR-1S) may also be required. *te: If you are registering an in-state business or property location, you must submit a $5 fee with this application. Online registration is free. Documentary Stamp Tax Complete Sections NO fee A, F, and H Entering into written financing agreements (five or more transactions per month). Making title loans. Self-financing dealers (buy here pay here). Banks, mortgage companies, and consumer finance companies. Promissory notes. Use Tax Complete Sections NO fee A, B, and H Any taxable purchases that were not taxed by the seller at the time of purchase. Repeated untaxed purchases through the Internet or from out-of-state vendors. Any purchases originally for resale, but later used or consumed by your business or for personal use. Use of dyed diesel fuel for off-road purposes. Unemployment Tax Complete Sections NO fee A, D, and H Paid wages of $1,500 in any quarter or employed at least one worker for 20 weeks in a calendar year. (Payments made to corporate officers are wages.) Applicant is a governmental entity, Indian tribe or tribal unit. Hold a section 501(c)(3) exemption from federal income tax and employ four or more workers for 20 weeks in a calendar year. Agricultural employer with a $10,000 cash quarterly payroll, or who employs five or more workers for 20 weeks in a calendar year. Private home or college club that paid $1,000 cash in a quarter for domestic services. Acquired all or part of the organization, trade, business, or assets of a liable employer. Liable for federal unemployment taxes. Previously liable for unemployment tax in the State of Florida. Gross Receipts Tax New for 2006 Complete Sections NO fee A, E, and H Sales or delivery of electricity or gas. Importation /severance of electricity or natural gas for one s own use where gross receipts tax has not been paid. Register Online It s FREE, fast, easy, and secure You can file this application online, via the Department s Internet site at eservices/apps/register. There is no fee for Internet registration. See instructions, next page. Solid Waste Fees and Pollutants Tax Complete Sections A, B, C, and H Communications Services Tax Complete Sections NO fee A, G, and H Sales of communications services (telephone, paging, certain facsimile services, videoconferencing). Sales of cable services. Sales of direct-to-home satellite services. Resellers (for example, pay telephones and prepaid calling arrangements). Seeking a direct pay permit. Pay $30 fee (drycleaning only)* Sales of new tires for motor vehicles. Sales of new or remanufactured lead-acid batteries. Rental or lease of motor vehicles to others. Sales of dry-cleaning services (plants or drop-off facilities). *te: You must submit a $30 fee with this application. Online registration is free.

27 How can I register online? The DR-1 application is on the Department s web site at register. An interactive wizard will guide you through an application from start to finish. Before you begin, gather specific information about your business activities, location, and beginning dates. There are no fees for online registration. Sales and use tax certificate numbers will be issued within three business days of your online submission. After that time, you can return to the site and retrieve your certificate number. How can I be sure that the information I submit online is secure? The Department s Internet registration site uses 128-bit secure socket layer technology and has been certified by VeriSign, an industry leader in data security. If a husband and wife jointly operate and own a business, what type of ownership must we indicate? rmally, when a husband and wife jointly own and operate a business, the ownership is a partnership. We suggest you contact the Internal Revenue Service for more information on partnership reporting requirements. What will I receive from the Department once I register? 1. A Certificate of Registration or notification of liability for the tax(es) for which you registered. Alachua Service Center US Highway 441 Ste 100 Alachua FL (ET) Clearwater Service Center Arbor Shoreline Office Park US Highway 19 N Ste 200 Clearwater FL (ET) Cocoa Service Center 2428 Clearlake Rd Bldg M Cocoa FL (ET) Coral Springs Service Center Florida Sunrise Tower 3111 N University Dr Ste 501 Coral Springs FL (ET) Daytona Beach Service Center 1821 Business Park Blvd Daytona Beach FL (ET) FLORIDA DEPARTMENT OF REVENUE SERVICE CENTERS Fort Myers Service Center 2295 Victoria Ave Ste 270 Fort Myers FL (ET) Fort Pierce Service Center Benton Building 337 N US Highway 1 Ste 207-B Fort Pierce FL (ET) Hollywood Service Center* Taft Office Complex 6565 Taft St Ste 300 Hollywood FL (ET) *Office closing vember 30, 2009 Jacksonville Service Center 921 N Davis St A250 Jacksonville FL (ET) Key West Service Center 3104 Flagler Ave Key West FL (ET) 2. Personalized returns or reports for filing, with instructions. 3. For active sales tax and communications services tax dealers, an Annual Resale Certificate will accompany the Certificate of Registration. What is an Annual Resale Certificate? The Department issues Annual Resale Certificates to active, registered sales tax dealers and communications services tax dealers. The Annual Resale Certificate allows businesses to make tax-exempt purchases from their suppliers, provided the item or service is purchased for resale. A copy of a current Annual Resale Certificate must be extended to the supplier; otherwise, tax must be paid on the transaction at the time of purchase. Tax Information Publication (TIP) 99A01-34 explains the resale provisions for sales and use tax. TIP 01BER-01 explains the resale provisions for communications services tax. Consult the Department s Internet site for further information. Misuse of the Annual Resale Certificate will subject the user to penalties as provided by law. What are my responsibilities? 1. You must register for all taxes for which you are liable before beginning business activities, otherwise you may be subject to penalties. For more information, visit our Internet site or contact Taxpayer Services. 2. Complete and return this application to the Florida Department of Revenue with the applicable registration fee. IF MAILING, DO NOT SEND CASH. SEND CHECK OR MONEY ORDER. Lake City Service Center 1401 W US Highway 90 Ste 100 Lake City FL (ET) Lakeland Service Center 115 S Missouri Ave Ste 202 Lakeland FL (ET) Leesburg Service Center 1415 S 14th St Ste 103 Leesburg FL (ET) Maitland Service Center Ste Maitland Center Parkway Maitland FL (ET) Marianna Service Center 4230 Lafayette St Ste D Marianna FL (CT) 3. Collect and/or report tax appropriately, maintain accurate records, post your certificate (if required), and file returns and reports timely. A return/report must be filed even if no tax is due. 4. tify the Department if your address changes, your business entity or activity changes, you open additional locations, or you close your business. 5. Provide your certificate or account number on all returns, remittances, and correspondence. What if my business has more than one location? Sales tax: You must complete a separate application for each location. Gross receipts tax on electric power or gas: You have the option of registering all locations under one account number or separately registering each location. Documentary stamp tax: You must register each location where books and records are maintained. Communications services tax and unemployment tax: You must register each entity that has its own Federal Employer Identification Number (FEIN). Solid waste fees and pollutants tax (rental car surcharge): You must register for each county where you have a rental location. What if I am managing commercial or residential rental property for others? For sales tax, commercial property managers must use this application; residential property managers may use Form DR-1C, Application for Collective Registration for Rental of Living or Sleeping Accommodations. Contact Account Management at for assistance. Miami Service Center 8175 NW 12th St Ste 119 Miami FL (ET) Naples Service Center 3073 Horseshoe Dr S Ste 110 Naples FL (ET) Orlando Service Center Regions Bank Building 5401 S Kirkman Rd 5th Floor Orlando FL (ET) Panama City Service Center 210 N Tyndall Parkway Panama City FL (CT) Pensacola Service Center 3670C N L St Pensacola FL (CT) Port Richey Service Center 6709 Ridge Rd Ste 300 Port Richey FL (ET) Sarasota Service Center Sarasota Main Plaza 1991 Main St Ste 240 Sarasota FL (ET) Tallahassee Service Center 267 John Knox Rd Ste 200 Tallahassee FL (ET) Tampa Service Center Ste E Martin Luther King Blvd Tampa FL (ET) West Palm Beach Service Center 2468 Metrocentre Blvd West Palm Beach FL (ET) CT Central Time ET Eastern Time Before returning application, remove this page and retain for future reference. Account Management 5050 W Tennessee St Tallahassee, FL Taxpayer Services or TDD: Internet Site Tax Law Library

28 ** PLEASE TYPE OR PRINT CLEARLY ** 4. Legal name of corporation, individual owner (last, first, middle) limited liability company, partnership, or other: 5. Trade or fictitious name (d/b/a) (if different than #4 above): 6. Complete physical address of business or real property. Home based businesses and non-permanent flea market/craft show vendors must use their home addresses. Listing a post office box, private mailbox, or rural route number is not permitted. City/State/ZIP: 7. Mailing address (if different than physical address): Mailing address: City/State/ZIP: APPLICATION TO COLLECT AND/OR REPORT TAX IN FLORIDA SECTION A BUSINESS INFORMATION Please use BLACK or BLUE ink ONLY and type or print clearly. Answer ALL questions in the section(s) that apply to your business. A. New business B. New business C. New tax obligation entity location at existing location Provide certificate number if you checked B or C: Beginning date of business activity: month day year Provide the date this business location or entity became or will become liable for Florida tax(es). Do not use your incorporation date unless that is the date your business became liable for tax. If you have been in business longer than 30 days prior to registering, contact the DOR service center nearest you. 3. If this is a seasonal business (not open year-round), list the months of your open season. Beginning date: 1. This application is for (check all that apply): Tax Type Fee Due Complete Sections Sales and Use Tax $5.00 * A, B, H Use Tax Only fee A, B, H Solid Waste Fees and Pollutants Tax $30.00** A, B, C, H Unemployment Tax fee A, D, H Gross Receipts Tax on Electric Power and Gas fee A, E, H Documentary Stamp Tax fee A, F, H address: D. Change of county location E. Change of F. Change of (Business is moving from legal entity ownership one Florida county to another) If you have checked Box D, E, or F, the Department will cancel your existing certificate(s) and issue a new one. Provide the certificate number(s) to be canceled. (Attach additional sheet if necessary.) This change is effective (enter date): month day year Ending date: month day year month day year Owner telephone number: Business telephone number: Fax number: 8. If you have a Consolidated Sales Tax Number and want to include this business location, please complete the following: 8 0 Consolidated registration name on record with the Florida Department of Revenue. Consolidated registration number If you want to obtain a new consolidated number, contact the Department and request Form DR-1CON. 9. Business Entity Identification Number. If you are registering for unemployment tax or have employees, you must provide an FEIN. If an FEIN is not required for your business entity, the social security number of the owner is required. Please read the explanation of the Department s use of social security numbers*on Page 6. (If you are required to have an FEIN, a. Federal Employer Identification Number (FEIN): but have not yet been assigned one you or may call the Internal Revenue Service at b. Social Security Number (SSN) of owner: to request one.) County: DR-1 R. 09/09 Page 1 *The $5 registration fee does not apply if: Your business location is outside the State of Florida. Your business is moving from one Florida county to another. You register online. **The $30 registration fee applies to drycleaning only. There is no Communications Services Tax fee A, G, H fee for online registration. 2. Indicate whether this is a new registration (never before registered with the Florida Department of Revenue) or a change to an existing registration. New Registration Change to Existing Registration If your business is relocating within the same county, do not use this application. Contact the Department to change your address.

29 SECTION A BUSINESS INFORMATION (CONT D.) 10. Identify proprietors or owners, partners, officers, members, or trustees. Include the person whose social security number is listed under Question 9. Without this information, processing of your application may be stopped. (See Page 6*) DR-1 R. 09/09 Page 2 Name Title Social security number* and Driver license number and state Home address City/State/ZIP Telephone number ( _ ) _ - ( _ ) _ - ( _ ) _ - ( _ ) _ Type of ownership - Check the box next to the exact entity structure of your business. Sole proprietorship - An unincorporated business that is owned by one individual. Partnership - The relationship existing between two or more entities or individuals who join to carry on a trade or business. This includes a business jointly owned/operated by a husband and wife. Check one: General partnership Limited partnership Joint venture Married couple Corporation - A person or group of people who incorporate by receiving a charter from their state s Secretary of State (includes professional service corporations). Check one: C-corporation S-corporation t-for-profit corporation Limited liability company - Two or more entities (or individuals) who file articles of organization with their state s Secretary of State. Check one: Single-member LLC Multi-member LLC Check here if you elected to be treated as a corporation for federal income tax purposes. 12. If a partnership, corporation, or limited liability company, provide your fiscal year ending date: 13. If incorporated, chartered or otherwise registered to do business in Florida, provide your document/registration number from the Florida Secretary of State: 14. Is your business location rented from another person or entity? If yes, and you do not operate from your home, provide the following information. Business trust - An entity created under an agreement of trust for the purpose of conducting a business for profit (includes real estate investment trusts). n-business trust/fiduciary - An entity created by a grantor for the specific benefit of a designated entity or individual. Estate - An entity that is created upon the death of an individual, consisting of that individual s real or personal property. Owner or landlord s name Telephone number Address City/State/ZIP 15. a. What is your primary business activity? b. What are your taxable business activities? c. If known, enter your rth American Industry Classification System (NAICS) Code: To determine your NAICS code, go to month day Provide the date of incorporation, charter, or authorization to do business in Florida: month day year Date of death: Government agency - A legal government body formed by governing constitutions, statutes, or rules. Indian tribe or Tribal unit - Any Indian tribe, band, nation, or other organized group or community which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians (includes any subdivision, subsidiary, or business enterprise wholly owned by such an Indian tribe). te: If not incorporated, chartered or registered to do business in Florida, you may be required to do so. Call the Florida Department of State, Division of Corporations at for more information or visit

30 SECTION B SALES AND USE TAX ACTIVITY $5 FEE (IN-STATE ONLY) 16. Does your business activity include (check all that apply): a. Sales of property or goods at retail (to consumers)? b. Sales of property or goods at wholesale (to registered dealers)? c. Sales of secondhand goods? d. Rental of commercial real property to individuals or businesses? e. Rental of transient living or sleeping accommodations (for six months or less)? f. Management of transient living or sleeping accommodations belonging to others? g. Rental of equipment or other property or goods to individuals or businesses? h. Renting/leasing motor vehicles to others? i. Repair or alteration of tangible personal property? j. Charging admission or membership fees? k. Placing and operating coinoperated amusement machines at business locations belonging to others? l. Placing and operating vending machines at business locations belonging to others? m. Purchasing items to be included in a finished product assembled or manufactured for sale? SECTION C SOLID WASTE FEES AND POLLUTANTS TAX DR-1 R. 09/09 Page 3 n. Providing any of the following services? (Check all that apply.) n1. Pest control for nonresidential buildings n2. Cleaning services for nonresidential buildings n3. Detective services n4. Protection services n5. Security alarm system monitoring o. Purchasing items that were not taxed by the seller at time of purchase (includes, but is not limited to, purchases through the Internet, from catalogs, or from out-of-state sellers)? p. Using dyed diesel fuel for off-road purposes? q. Operating vending machine(s) owned by you at your business location? 17. What products or services do you purchase for resale? COIN-OPERATED AMUSEMENT MACHINES 18. Are coin-operated amusement machines being operated at your business location? If yes, answer question Do you have a written agreement that requires someone other than yourself to obtain amusement machine certificates for any of the machines at your location? If yes, provide their information below... Name Address Telephone number te: You must complete an Application for Amusement Machine Certificate (Form DR-18) if you answered YES to question 18 and NO to question 19. CONTRACTORS 20. Do you improve real property as a contractor? If yes, answer questions Do you sell tangible personal property at retail? Do you purchase materials or supplies from vendors located outside of Florida? Do you fabricate or manufacture any building component at a location other than contract sites?... MOTOR FUEL 24. Do you sell any type of fuel or use off-road, dyed, diesel fuel? If yes, answer questions 25 and a. Do you make retail sales of gasoline, diesel fuel, or aviation fuel at posted retail prices?... b. If yes to #25a, does this business exist as a marina?... c. If yes to #25a, do you expect to sell more diesel fuel than gasoline?... d. If yes to #25a, provide your Florida Department of Environmental Protection facility identification number for this location. 26. Do you use dyed diesel fuel for off-road purposes that was not taxed at the time of purchase?... $30 FEE FOR DRYCLEANING ONLY 27. Do you sell tires or batteries, or rent/lease motor vehicles to others? If yes, answer questions Do you make retail sales of new tires for motorized vehicles (either separately or as a part of a vehicle)? Do you make retail sales of new or remanufactured lead-acid batteries sold separately or as a component part of another product such as new automobiles, golf carts, boats, etc.? Are you in the business of renting or leasing vehicles that transport fewer than nine passengers to individuals or businesses? Do you own or operate a dry-cleaning dry drop-off facility or plant in Florida?... If yes, enclose the $30 dry-cleaning registration fee. 32. Do you produce or import perchloroethylene?... If yes, you must complete an Application for Florida License to Produce or Import Taxable Pollutants (Form DR-166).

31 SECTION D UNEMPLOYMENT TAX NO FEE DR-1 R. 09/09 Page 4 If you are registering an additional business location and are already registered with the Florida Department of Revenue for unemployment tax, you do not need to complete this section. If you need to reactivate a previously assigned unemployment tax (UT) account number, enter your account number and complete items below. Make sure that you have entered your FEIN on page 1, item Employer type (check all that apply): Regular (If a leasing company, Agricultural (citrus) Governmental entity nprofit organization attach copy of license.) (501(c)(3) letter must be attached) Domestic (household) Agricultural (non citrus) Agricultural crew chief Indian tribe / Tribal unit 34. Did your business pay federal unemployment tax in another state in the current or previous calendar year?... If yes, in which state(s) Year(s) 35. Do you lease any of your employees? If yes, check whether all or part of your workforce is leased:... All Part Leasing Company Name: DBPR License Number: Date leasing began: Leasing Company s FEIN: Leasing Company s UT Acct. Number: 36. For the current calendar year, how many full or partial weeks have you employed workers? For the previous year, how many full or partial weeks did you employ workers? 37. Provide the date that you first employed or will employ workers in Florida. month day year 38. Does another party (accountant, bookkeeper, agent) maintain your payroll?... If yes, provide the following information. Name of agent Address Telephone number City/State/ZIP 39. Provide only your Florida gross payroll by calendar quarters. Estimate amounts if exact figures are not available. Qtr Ending 3/31 Qtr Ending 6/30 Qtr Ending 9/30 Qtr Ending 12/31 Current year $ $ $ $ Previous year $ $ $ $ Next previous year $ $ $ $ Next previous year $ $ $ $ Next previous year $ $ $ $ 40. Did you purchase this business from another entity or change your current business structure in any way?... If yes, complete items a through i below, providing information about the former entity. Also, complete and submit a Report to Determine Succession and Application for Transfer of Experience Rating Records (Form UCS-1S) to the Department of Revenue. This form must be postmarked within 90 days of the acquisition date to be considered timely. a. Legal name of former entity b. FEIN c. UT account number d. Trade name (d/b/a) e. Address f. Date of purchase/change g. Portion of business acquired: All Part Unknown h. Was the business in operation at the time the purchase/change occurred? If no, provide date business closed. i. Was there any common ownership, management, or control at the time the purchase/change occurred? 41. List the locations and nature of business conducted in Florida. Use additional sheets if necessary. Address, city, and county of work site Principal products / services Number of employees Do the above work sites provide support for any other units of the company?... If yes, the services are: administrative research other, specify

32 DR-1 SECTION E GROSS RECEIPTS TAX NO FEE R. 09/09 Page Do you sell, deliver, or transport electricity or gas? If yes, check the items below that apply:... a. Electricity... b. Natural or manufactured gas? Do you import into this state, natural or manufactured gas for your own use as a substitute for purchasing taxable utility or transportation services?... SECTION F DOCUMENTARY STAMP TAX NO FEE 44. Do you make sales, finalized by written agreements, that do not require recording by the Clerk of the Court, but do require documentary stamp tax to be paid? If yes, answer questions Do you anticipate five or more transactions subject to documentary stamp tax per month? Do you anticipate your average monthly documentary stamp tax remittance to be less than $80 per month? Is this application being completed to register your first location to collect documentary stamp tax?... If no, and this application is for additional locations, please list name and address of each additional location. (Attach additional sheets if needed.) Location name Telephone number Physical address City/State/ZIP SECTION G COMMUNICATIONS SERVICES TAX NO FEE 48. Do you sell communications services? If yes, check the items below that apply... a. Telephone service (local, long distance, or mobile)... b. Paging service... c. Facsimile (fax) service (not in the course of advertising or professional services)... d. Cable service... e. Direct to home satellite service... f. Pay telephone service... g. Reseller (only sales for resale; no sales to any retail customers)... h. Other services; please describe:. 49. Do you purchase communications services to integrate into prepaid calling arrangements? Are you applying for a direct pay permit for communications services? Check the appropriate box(es) for the method(s) you intend to use for determining the local taxing jurisdictions in which service addresses for your customers are located. If you use multiple databases, check all that apply. If you only sell pay telephone or direct-to-home satellite services, provide prepaid calling arrangements, are a reseller, or are applying for a direct pay permit, skip questions 51 and An electronic database provided by the Department. 2a. A database developed by this company that will be certified. To apply for certification of your database, complete an Application for Certification of Communications Services Database (Form DR ). 2b. A database supplied by a vendor. Provide the vendor s name: Two collection allowance rates are available. Dealers whose databases meet the criteria in items 1, 3, or 4 above are eligible for a.75 percent (.0075) collection allowance. Dealers whose databases meet the criteria in item 5 are eligible for a.25 percent (.0025) collection allowance. Dealers meeting the criteria in item 2a are eligible for a.25 percent (.0025) collection allowance until the database is certified. Upon certification, the dealer will receive the.75 percent (.0075) collection allowance. Dealers meeting the criteria in 2b are eligible for the.75 percent (.0075) collection allowance if the vendor s database has been certified. If not, the.25 percent collection allowance (.0025) will apply. 3. ZIP+4 and a methodology for assignment when ZIP codes overlap jurisdictions. 4. ZIP+4 that does not overlap jurisdictions. Example: a hotel located in one jurisdiction. 5. ne of the above. Dealers with multiple databases may need to file two separate returns in order to maximize their collection allowances. If all databases are certified or a ZIP+4 method is used, then the dealer is entitled to the.75 percent (.0075) collection allowance. If some databases are certified or a ZIP+4 method is used, and some are not, the dealer has two options for reporting the tax. One is to file a single return for all taxable sales from all databases and receive a.25 percent (.0025) collection allowance. The second option is to file two returns: one reporting taxable sales from certified databases (.75 percent allowance) and a separate return for the taxable sales from non-certified databases (.25 percent allowance). If no databases are certified, the dealer will receive a.25 percent (.0025) collection allowance on all tax collected. 52. If you wish to be eligible for both collection allowances, check the box below to indicate that you will file two separate returns. I will file two separate communications services tax returns in order to maximize my collection allowance. 53. Provide the name of the managerial representative who can answer questions regarding filed tax returns. Name Address Telephone Street Address

33 SECTION H APPLICANT DECLARATION AND SIGNATURE This application will not be accepted if not signed by the applicant. If the applicant is a sole proprietorship, the proprietor or owner must sign; if a partnership, a partner must sign; if a corporation, an officer of the corporation authorized to sign on behalf of the corporation must sign; if a limited liability company, an authorized member or manager must sign; if a trust, a trustee must sign; if applicant is represented by an authorized agent for unemployment tax purposes, the agent may sign (attach executed power of attorney). THE SIGNATURE OF ANY OTHER PERSON WILL NOT BE ACCEPTED. Please note that any person (including employees, corporate directors, corporate officers, etc.) who is required to collect, truthfully account for, and pay any taxes and willfully fails to do so shall be liable for penalties under the provisions of section , Florida Statutes. All information provided by the applicant is confidential as provided in s , F.S., and is not subject to Florida Public Records Law (s , F.S.). Under penalties of perjury, I attest that I am authorized to sign on behalf of the business entity identified herein, and also declare that I have read the information provided on this application and that the facts stated in it are true to the best of my knowledge and belief. SIGN HERE Print name DR-1 R. 09/09 Page 6 Title Date Amount enclosed: $ Complete the application in its entirety. Make sure that you have provided your FEIN or SSN. Sign and date the application. Attach check or money order for appropriate registration fee amount. DO NOT SEND CASH. PM/Delivery B.P.. UT Acct... $5 fee Sales tax registration for business/property located in Florida. $30 fee Solid waste registration for dry cleaners. USE THIS CHECKLIST TO ENSURE FAST PROCESSING OF YOUR APPLICATION. FOR DOR USE ONLY - Contract Object (MO) Contract Object (LO) Contract Object (other) Mail to: FLORIDA DEPARTMENT OF REVENUE 5050 W TENNESSEE ST TALLAHASSEE FL You may also mail or deliver your application to any service center listed on the inside front cover. NAICS Code(s): *Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida s taxes. SSNs obtained for tax administration purposes are confidential under sections and , Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select Privacy tice for more information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

34 Business License Research & Compliance Package Business Tax Registration (Municipality/Township, Vero Beach, 32963) If you have questions regarding this application, please contact the issuing authority using the information provided below. Issuing Office Mailing Address Mail the application to the mailing address provided below, unless otherwise noted on the form. General tes Information pertaining to this form

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