Planning & Development
1400 North Boulevard Tampa, FL 33607
(813) 274-3100
DAR EMPLOYMENT AFFIDAVIT
REV 01/21/20
DULY AUTHORIZED REPRESENTATIVE (DAR)
Employment Affidavit
This affidavit is required pursuant to the City of Tampa Private Provider Review and
Inspection Registration Program. F.S. 553.791 (8).
The authorization(s) for the listed individual(s) will remain in effect, unless cancelled in writing,
by the undersigned.
Private Provider Name (Printed): ___________________________________________________
Private Provider License No: __________________________________________________________________
I, , the Private Provider, do hereby affirm that the Duly
Authorized Representatives listed below are my employees, as required by Florida Statute
553.791 and are entitled to receive unemployment compensation benefits under Chapter 443.
Printed or Typed Name of Private Provider Signature of Private Provider
NOTARY
STATE OF FLORIDA
COUNTY OF
SWORN TO (OR AFFIRMED) AND SUBSCRIBED before me this day of ,
20 , by (name of person making statement).
Signature of Notary Public State of Florida
(NOTARY SEAL)
Printed or Typed Name of Notary Public
click to sign
signature
click to edit
click to sign
signature
click to edit
Planning & Development
1400 North Boulevard Tampa, FL 33607
(813) 274-3100
DAR EMPLOYMENT AFFIDAVIT
REV 01/21/20
DULY AUTHORIZED REPRESENTATIVE (DAR)
Employment Affidavit
The law requires that all Duly Authorized Representatives (DAR) are employees of
the Private Provider firm and as such, entitled to receive unemployment benefits
under Chapter 443 of the Florida Statutes.
DULY AUTHORIZED REPRESENTATIVES
If more space is needed to list all DARs, please submit a supplementary
signed/sealed form with the information. You must also submit copies of license(s)
for each DAR listed (screen print from DBPR website is acceptable).
Name (Printed)
FL License
No(s)
Discipline
DAR Signature
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome