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Florida Department of Agriculture and Consumer Services

NICOLE "NIKKI" FRIED, Commissioner
EXAM APPLICATION FOR PUBLIC HEALTH APPLICATOR
Section 388, F.S., and Rule 5E-13.040 F.A.C.
Applicant must be 18 years of age or older to apply. Provide the details below. Fields marked with red asterisk are required. (Date Format: mm/dd/yyyy, Phone Format: 999-999-9999)
Examination Purpose
* If exists, License#:
Applicant Information
First Name: * Middle Name: Last Name: * Suffix:
Date of Birth: * Place of Employment: Title:
Florida Resident: * Email: * Business Email:
    Either home phone or cell phone is required. Format: 999-999-9999.
Home Phone: Cell Phone: Business Phone: Fax Number:
Address Information
Home (Physical) Address: * Line 2: Home City: * State: * Zip Code: *
Mailing:* Line 2: Mailing City: * State: * Zip Code: *
Business Address: Line 2: Business City: State: Zip Code: