Fillable COMMERCIAL TELEPHONE SALESPERSON INDIVIDUAL LICENSE APPLICATION (Florida Department of Agriculture and Consumer Services)

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COMMERCIAL TELEPHONE SALESPERSON INDIVIDUAL LICENSE APPLICATION (Florida Department of Agriculture and Consumer Services)

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FDACS-10005 Rev. 04/19
Page 1 of 4
NICOLE “NIKKI” FRIED
COMMISSIONER
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
COMMERCIAL TELEPHONE SALESPERSON
INDIVIDUAL LICENSE APPLICATION
Section 501.607, Florida Statutes
Rule 5J-6.005, Florida Administrative Code
1-800-HELP-FLA (435-7352) • (850) 410-3800
www.FDACS.gov • (850) 410-3804 Fax
All documents and attachments submitted with this application may be subject to public review pursuant to Chapter 119, Florida
Statutes (F.S.). PLEASE TYPE OR PRINT. Attach additional pages as necessary using the same format. Please ensure
that all attachments reflect the organization’s name or registration number and the number of the corresponding question.
Annual Registration Fee: $50.00. Active duty military, honorably discharged veterans, military spouses or surviving spouses
may be eligible for a waiver of the registration fee. See sections 501.607(2)(b) and 501.609(5), F.S., and rule
5J-6.005, Florida Administrative Code, for eligibility requirements.
Please Select one:
New Filing
Renewal
TP
(as issued by the department and listed on the preprinted renewal application)
APPLICANT INFORMATION [s.501.607(1)(a), F.S.]
1.
Legal (True) Name:
Date of Birth:
/
/
Driver’s License or Government Issued ID Number:
State of Issue:
Street Address (if applicable please include suite, apartment and/or unit numbers):
City:
State:
Zip Code:
-
Email Address:
Telephone Number:
( ) -
EMPLOYER INFORMATION
2.
Employer’s Legal Name (If employer is not an individual, state the legal name of the entity as filed with the Florida Department of State):
License Number, Issued by the Department:
Physical Street Address (if applicable please include suite, apartment and/or unit numbers):
City:
State:
Zip Code:
-
Org. Code: 42 10 06 25 000
EO: A2
Object Code: 002051 $50.00
Submit and Pay Non-
Refundable Fee online at:
www.FDACS.gov
- or -
Check or Money Order payable
to FDACS and remit with
application to:
FDACS
PO Box 6700
Tallahassee, FL 32314-6700
F&A Use Only
FDACS-10005 Rev. 04/19
Page 2 of 4
Telephone Number:
(
)
-
N
OTE: If you intend to act as a salesperson for more than one company, please provide us with the additional
employer information on a separate page and attach it to this application. You must include a Statement of
Verification (located on page 4) for each commercial telephone seller with which you intend to affiliate.
3.
Do you have previous experience as a commercial telephone seller or salesperson?
Yes No
If yes, previous experience (in months) as a commercial telephone seller or salesperson:
CRIMINAL AND LITIGATION HISTORY
4.
Please select either YES or NO to the questions below. If you answered YES to any of the following, please explain
your answer on “Exhibit A” located on the following page (make additional copies as needed).
a.
Have you, regardless of adjudication, previously been arrested for, convicted or found guilty of, or entered
a plea of guilty or nolo contendere to,
any felony crime within the last seven (7
) years that involves
racketeering or any offense involving robbery, carjacking, attempted carjacking, home invasion, or
misappropriation of moneys by commissioners to make sales? [Subsection 5J-6.014(4), F.A.C.]
Yes No
b.
Have you, regardless of adjudication, previously been arrested for, convicted or found guilty of, or entered
a plea of guilty or a plea of nolo
contendere to,
any felony crime within the last five (5) years that involves
fraud, theft, embezzlement, fraudulent conversion, or misappropriation of property
? [Subsection 5J-
6.014(3),
F.A.C.]
Yes
No
c.
Have you, regardless of adjudication, previously been convicted or found guilty of, or entered a plea of
guilty or a plea of nolo contendere to,
any misdemeanor crime within the last three (3) years that involves
fraud, theft, embezzlement, fraudulent conversion, or misappropriation of property, or any other crime
involving moral turpitude? [Subsection 5J-6.014(1), F.A.C.]
Yes
No
d.
Has there ever been a judicial or administrative finding that the applicant has previously been convicted
of acting as a salesperson without a license,
or h
as such a license previously been refused, revoked, or
suspended in any jurisdiction? [s. 501.607(1)(e), F.S.]
Yes No
e.
Have you ever applied for a salesperson license that has been refused, or had a salesperson license
revoked or suspended in any jurisdiction? [s. 501.607(1)(e), F.S.]
Yes
No
f.
Have you ever worked for, or been affiliated with, a company that is involved in pending litigation or has
had entered against it an injunction, a temporary restraining order, or a final judgment or order, including
a stipulated judgment or order, an assurance of voluntary compliance, or any similar document, in any
civil or administrative action involving racketeering, fraud, theft, embezzlement, fraudulent conversion, or
misappropriation of property or the use of any untrue, deceptive, or misleading representation or the use
of any unfair, unlawful, or deceptive trade practice? [s. 501.607(1)(f), F.S.]
Yes No
g.
Are you involved in pending litigation or have you had entered against you an injunction, a temporary
restraining order, or a final judgment or order, including a stipulated judgment or order, an assurance
of voluntary compliance, or any similar document, in any civil or administrative action involving
racketeering, fraud, theft, em
bezzlement, fraudulent conversion, or misappropriation of property or
the use of any untrue, deceptive, or misleading representation or the use of any unfair, unlawful, or
deceptive trade practice?
[s. 501.607(1)(g), F.S.]
Yes No
FDACS-10005 Rev. 04/19
Page 3 of 4
Exhibit A
Legal (True) Name at the time of the action:
Court or administrative agency rendering the decision, judgment or order:
Governmental agency which brought the action:
Nature of the crime, judgment, order or action:
Date of Action:
Docket Number:
/
/
Please attach additional pages as necessary using the same format.
It is a violation of the Florida Telemarketing Act for a salesperson to fail to maintain a valid license; advertise that one is
licensed as a salesperson or to represent that such licensing constitutes approval or endorsement by any government or
governmental office or agency; provide inaccurate or incomplete information to the department when making a license
application; or misrepresent that a person is registered or that such a person has a valid license number.
The department has adopted rules which allow certain salesperson applicants to operate on an interim basis until such time
as a license is granted or denied, such interim authority is not to exceed 90 days. If an interim license has not been granted,
then it is unlawful for a salesperson to begin conducting commercial telephone solicitation before such license is issued.
I understand that the Florida Department of Agriculture and Consumer Services will conduct an investigation of my
background. In that regard, I hereby waive any right of confidentiality as it reasonably relates to this inquiry.
[s. 501.607, F.S.]
I hereby give my permission and waive any provisions of law that forbid any court, police agency, employer, firm or person
from disclosing any knowledge or information they have concerning me which is requested by the Florida Department of
Agriculture and Consumer Services. I further consent and request that the Director of the Division of Consumer Services,
or the Director’s representative, be provided with a certified copy of any such record concerning me which they may deem
necessary in the performance of their investigation.
Any commercial telephone seller or salesperson who falsifies information on an application commits a felony of the third
degree, punishable as provided in section 775.082, 775.083, or 775.084, F.S.
I DECLARE UNDER PENALTY OF PERJURY THAT ALL OF THE INFORMATION PROVIDED IN THIS APPLICATION,
AND IN ANY EXHIBITS ATTACHED HERETO, IS TRUE AND CORRECT.
Applicant Signature
Print or Type Applicant Name
Date
ADDITIONAL INFORMATION
Material Change: Submit FDACS-10006, Florida Telemarketing Act Material Change Form, Rev. 07/17 and, if
applicable, a fee of $10 to the department, within ten (10) days of any changes made to the information provided within
the application.
(s. 501.609(2), (4), F.S.)
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FDACS-10005 Rev. 04/19
Page 4 of 4
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
NI
COLE “NIKKI” FRIED
COMMISSIONER
STATEMENT OF VERIFICATION
Section 501.607(2)(a), Florida Statutes
1-800-HELP-FLA (435-7352) • (850) 410-3800
www.FDACS.gov • (850) 410-3804 Fax
I,
,
represent that I am a licensed commercial
Business Representative
telephone seller with
with whom
Legal Name of Telephone Seller – Business
will be associated in the activity of commercial telephone solicitation.
Name of Salesperson
It is my desire to associate the individual above as a salesperson and I will accept all responsibility and liability for the
commercial telephone solicitation activities of the salesperson, while acting within the scope of his/her employment.
I certify that I am authorized to complete this St
atement of Verification and that the information provided is true and accurate.
Signature of Business Representative
Date
( ) -
Email Address
Telephone Number
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COMMERCIAL TELEPHONE SALESPERSON INDIVIDUAL LICENSE APPLICATION (Florida Department of Agriculture and Consumer Services)

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Completed 6 October 2021

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