DBPR 0090 – Duplicate License Request STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION LICENSEE INFORMATION License Number Licensee Name Social Security Number*/Federal Employer ID Number MAILING ADDRESS Street Address or P.O. Box City State County (if Florida address) Zip Code (+4 optional) Country I hereby certify that the license issued by the Florida Department of Business and Professional Regulation was (check one): Lost Stolen – no charge (requires police report) Destroyed *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 455.203(9), 409.2577, and 409.2598, 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. 317. I affirm that I have provided the above information completely and truthfully to the best of my knowledge. Licensee Sign Here: Date: FOR DIVISION USE ONLY Duplicate License Issued By: Date Issued: Fee for duplicate licenses $25, except: Boxing $15 Appraisers $20 Surveyors & Mappers $20 Pari-Mutuel Wagering & Slots – No fee Land Sales, Condominium & Mobile Homes – No fee Yacht & Ship Brokers – No fee Hotels & Restaurants – No fee Elevators – No fee Labor Organizations – No fee 1 Rev 6/14/2007 American LegalNet, Inc. www.FormsWorkflow.com