Revision 10/17
Experience One Year
I certify that I have completed the following for a period no less than one (1) year within the past four (4) years as a
substantially full time bona fide employee of title insurance:
Abstracting and title searches; or
Title examination; or
Preparation of title insurance policies; or
Closing documents; or
Handling escrow and trust funds; or
Disbursement of trust funds; or
Preparation of documents; or
Recording documents; and
Gaining general knowledge of title insurance work and office management in the operation of a title
insurance office
Note: You must attach a typed statement with a detailed account of your experience.
As applicant’s current or prior employer, I certify that the applicant has completed the above experience qualification,
and that compensation did/did not include, in whole or any part, any commissions and was not primarily based in the
production of applications, insurance or premiums, except in cases where the applicant may have been properly
licensed in this or another state and therefore, authorized to receive such compensation. I further certify that this
applicant has not transacted business in violation of the Florida Statutes.
By signature of this form, applicant/employer declares, under penalty of perjury, that the foregoing statements and facts
stated herein are true and correct:
________________________________________ ________________________________________
Applicant Signature Employer Signature
________________________________________ ________________________________________
Print Applicant Name Print Employer Name
________________________________________ ________________________________________
Applicant’s Social Security Number Agency Name
Agency Address
City State Zip
Division of Agent and Agency Services Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
Revision 10/17
Division of Agent and Agency Services Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
Privacy Statement
Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the State is responsible for informing you
whether disclosure of your social security number is mandatory or voluntary, by what statutory or
other authority your social security number is solicited, and what uses will be made of your social
security number. Under § 119.071(5)(a)2.a., F.S., a state agency may collect your social security
number if the collection is:
(I) specifically authorized by law; or
(II) imperative for the performance of the agency’s duties and responsibilities as
prescribed by law.
Disclosure of your social security number on this form is mandatory pursuant to the Welfare
Reform Act, 42 U.S.C. § 666, and §§ 626.171(2)(a) and (7), 626.231(2)(a), 626.541(1), and
626.9953(3)(a) and (7), F.S.
The purposes for the requested information are to verify the identity of an applicant for licensure,
to conduct criminal and disciplinary history background checks, and to determine if the applicant
lacks the fitness or trustworthiness to engage in the business of insurance. Your social security
number is confidential and exempt from the disclosure requirements of § 119.07(1), F.S., and §
24(a), Article I of the Florida Constitution and will not be used for any purpose other than the
purposes provided herein, or as otherwise authorized under § 119.071(5)(a), F.S.
A copy of this Privacy Statement is provided to you as required by § 119.071(5)(a)3., F.S.