DBPR PMW-3195, Effective 9-12-12, Rule 61D-4.002, F.A.C. Page 1 of 1 1.1
DBPR PMW-3195 – Request for Release of Information and Authorization to Release Information
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
DIVISION OF PARI-MUTUEL WAGERING
www.myfloridalicense.com
PERSONAL INFORMATION
Social Security Number/Federal Employer ID Number
IF INDIVIDUAL APPLICANT, PLEASE COMPLETE THE FOLLOWING SECTION
Last Name First Middle Title Suffix
Birth Date (MM/DD/YYYY)
IF BUSINESS APPLICANT, PLEASE COMPLETE THE FOLLOWING SECTION
Representative’s Name Last First Middle Title Suffix
Permitholder Name
Official Capacity
ATTEST STATEMENT
I
,
, do hereby instruct all law enforcement
(name of applicant/representative)
or criminal justice agencies, present and former employers or institutions with whom I or my businesses
have a present or past business relationship, as well as all present or past social associates to release all
requested information to the bearer of this release form, who is an authorized representative of the State
of Florida, Department of Business and Professional Regulation.
I further authorize any individual, agency, corporation, or other entity to release any and all information
requested by the bearer of this release form with respect to myself or my business. Additionally, I do
release such individuals or entities from any and all liability due to the release of information requested.
(if individual applicant - legal name and any nickname or alias in parentheses)
Applicant/Representative Signature:
Date:
NOTARIZATION
The fore
going application was sworn to and subscribed before me this
Day of , 20 ,
by
,
Type or print name of applicant Signature of applicant
who i
s personally known to me or who has produced the following as identification.
Type of identification
Signature of person taking acknowledgement
Notary Seal
(Rubbe
r Stamp and Expiration)
