Fillable Doctor Verification Affidavit PDF (City of Hialeah)

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Doctor Verification Affidavit PDF (City of Hialeah)

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DoctorverificationAFF.doc
DoctorverificationAFF.doc
DoctorverificationAFF.doc
City of Hialeah
Business Tax Receipt Division
Doctor/Health Provider/Pharmacist Verification Affidavit
This is to inform the City of Hialeah that I, ____________________________________ will be
working at the following facility: ________________________________________________
located at ________________________________________Hialeah, FL _____________.
My State License is ____________________________ Expires on _________________.
and my Driver’s License number is _________________Expires on _________________.
I understand that when I cease work at the above location I will notify the Business Tax
Receipt Division by form of a letter to cancel my license.
_____________________________________ ___________________
Signature of Applicant Date
``
State of Florida. County of Dade.
Sworn and subscribed before me this __________ day of ______________, 20______.
_______________________________ ___________________________________
My commission Expires Notary Public, State of Florida
Print, type or stamp Notary’s name.
Personally Known
Produced I.D. ______________________________________________
Type of Identification
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Doctor Verification Affidavit PDF (City of Hialeah)

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Completed 15 July 2020

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