Fill - Free fillable MASTER/JOURNEYMAN RECIPROCITY APPLICATION AND FEES Application Fees (Brevard County Board of Commissioners) PDF form

Master-Journeyman Reciprocity Application 01/13/2020

Licensing Regulation & Enforcement

2725 Judge Fran Jamieson Way, Bldg. A-114

Viera, Florida 32940

Phone: (321) 633-2058, press 4, 6

contractorlicensing@BrevardFL.gov

MASTER/JOURNEYMAN RECIPROCITY APPLICATION AND FEES

APPLICATION FEES ARE NON-REFUNDABLE

Application Fees

JOURNEYMAN $25

Air Conditioning

Electrician

Plumber

Roofer

Sheetmetal

MASTER $115

Electrician

Plumber

Certification Fees

The Certification Fee is for the Competency Card and is prorated throughout the year. The

Competency Card expires every August 31

. The prorated fees are:

August – November 100% of Certification Fee

December – April 75% of Certification Fee

May – July 50% of Certification Fee

JOURNEYMAN $50 MASTER $75

The following documents must be submitted with application:

1. Application & Certification fees as indicated above

2. Copy of driver’s license

3. Copy of current Competency Card

4. Sponsoring County must state in their reciprocity letter they will reciprocate with Brevard

County in the same trade

5. Signed social Security Number Disclaimer

Make checks payable to Brevard County BOCC

Master-Journeyman Reciprocity Application 01/13/2020

Master/Journeyman Application for Reciprocity

Date ___________________ Trade Category ___________________________________________

Select one: Master Journeyman

Fees Attached: Application Fee $___________________ Certification Fee $_________________

1. Name (Last, First, MI) ____________________________________________________________

2. Address _______________________________________________________________________

3. Date of birth _______________________ Home Phone # ________________________________

4. Daytime Phone # __________________________ Fax # ________________________________

5. U S Citizen? Yes No

6. Height: ________ Weight: _________ Eye Color: ____________ Hair Color: ____________

EXPERIENCE INFORMATION – TO BE COMPLETED BY THE APPLICANT

Present Employer ___________________________________ Phone # _______________________

Address _________________________________________________________________________

Position Held ___________________________________ Length of employment ________________

Name and Address of Previous Employer

________________________________________________________________________________

Dates of Employment ______________________________ Position _________________________

Name and Address of Previous Employer

________________________________________________________________________________

Dates of Employment ______________________________ Position _________________________

Total years as Helper ___________ Total years as licensed Journeyman ___________

Master-Journeyman Reciprocity Application 01/13/2020

Master/Journeyman Application for Reciprocity

SCHOOLING – Provide copies of certificates/diplomas/transcripts

High School __________________________________________ # Years Attended _____________

College ______________________________________________ # Years Attended _____________

Apprenticeship School __________________________________ # Years Attended _____________

I certify that this information is true and correct to the best of my knowledge and that any willful

falsification of any information contained herein is grounds for disqualification.

Signature of Applicant __________________________________ Date _____________________

STATE OF _______________________

COUNTY OF _____________________

The foregoing instrument was acknowledged before me this ______ day of ________________,

20______, by _____________________________________ who is personally known to me _____

or who produced a ________________________________________ as identification.

(Notary Seal)

_________________________________

Signature of Notary

OFFICE USE ONLY

Cap ID or COC # __________________________________________

Reciprocity From __________________________________________

Date Certification Issued: _________________________ Invoice # __________________________

App Fee Pd $

Pymt Method

Date paid:

CLB Date:

Processed by:

Cert Fee Pd $

Pymt Method

Date paid:

SOCIAL SECURITY NUMBER DISCLAIMER

** "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 occupations

license applications and will be used for licensee identification pursuant to the Personal Responsibility

and Work Opportunity Reconciliation Act of 1996 (Welform Reform Act), 104 Pub.L. 193, Sec.317."

You must print your name, Social Security Number, date and sign that you have read the disclaimer

above:

________________________ ________________________

(Print Name) (Social Security Number)

__________________________________ Date ___________________

(Sign)

Please cut along dotted line and keep bottom portion of the disclaimer for your records

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