Cg 10R Application Form – Fill Out and Use This PDF

P E R S O N A L I N FO R M A TI O N

Co m p le te e ntire Ap p lic a tio n in UPPERC ASE le tte rs using o nly b lac k o r b lue ink.

1. So c ia l Se c urity Num b e r

2 . Birth Da te ( MM / DD / YYYY )

3 . A re yo u a US C itize n?

M

M

D

D

Y

Y

Y

Y

Ye s

No

4 . First Na m e

８１＃Ｐｌｇｇｏｈ＃Ｑｄｐｈ＃

6 . La st Na m e

RE N E W A L O R R E I N S TA TE M E N T RE Q U E S TE D

	Se rvic e	Ｇｈｖｆｕｌｓｗｌｒｑ＃ｒｉ＃Ｖｈｕｙｌｆｈ＃Ｕｈｔｘｈｖｗｈｇ＃	Fe e
	RENEWAL	Ｌ＃ｚｄｑｗ＃ｗｒ＃ｄｓｓｏ｜＃ｉｒｕ＃ＵＨＱＨＺＤＯ＃ｒｉ＃ｐ｜＃Ｉｏｒｕｌｇｄ＃Ｓｕｒｉｈｖｖｌｒｑｄｏ＃Ｆｈｕｗｌ￀ｆｄｗｈ＃ｚｋｌｆｋ＃ｋｄｖ＃ｑｒｗ＃｜ｈｗ＃	$75.00
		e xp ire d .
	LATE RENEWAL	Ｌ＃ｚｄｑｗ＃ｗｒ＃ｄｓｓｏ｜＃ｉｒｕ＃ＯＤＷＨ＃ＵＨＱＨＺＤＯ＃ｒｉ＃ｐ｜＃Ｉｏｒｕｌｇｄ＃Ｓｕｒｉｈｖｖｌｒｑｄｏ＃Ｆｈｕｗｌ￀ｆｄｗｈ＃ｚｋｌｆｋ＃ｋｄｖ＃	$105.00
		ｕｈｆｈｑｗｏ｜＃ｈ｛ｓｌｕｈｇ＃＋ｑｒｗ＃ｐｒｕｈ＃ｗｋｄｑ＃ｒｑｈ＃｜ｈｄｕ，１＃	＋＇：８＃ｓｏｘｖ＃＇６３＃Ｏｄｗｈ＃Ｉｈｈ，＃
	REINSTATEMENT	Ｌ＃ｚｄｑｗ＃ｗｒ＃ｄｓｓｏ｜＃ｉｒｕ＃ＵＨＬＱＶＷＤＷＨＰＨＱＷ＃ｒｉ＃ｐ｜＃ｈ｛ｓｌｕｈｇ＃Ｉｏｒｕｌｇｄ＃Ｓｕｒｉｈｖｖｌｒｑｄｏ＃Ｆｈｕｗｌ￀ｆｄｗｈ１＃	$75.00

	yxwvutsrponC o urse Num b e rNa m e o f Institutio n
S U B J E C TS R E N E W E D O R R E I N S TA TE D
Ｏｌｖｗ＃Ｖｘｅｍｈｆｗ＋ｖ，＃ｖｋｒｚｑ＃ｒｑ＃｜ｒｘｕ＃Ｓｕｒｉｈｖｖｌｒｑｄｏ＃Ｆｈｕｗｌ￀ｆｄｗｈ＃ｗｋｄｗ＃ｄｕｈ＃ｗｒ＃ｅｈ＃Ｕｈｑｈｚｈｇ＃ｒｕ＃Ｕｈｌｑｖｗｄｗｈｇ＃
				Ｐｈｗｋｒｇ＃ｒｉ＃Ｕｈｑｈｚｄｏ＃
Sub je c t(s)
Ｗｒ＃Ｅｈ＃Ｕｈｑｈｚｈｇ＃			C lle g e C re d it		Flo rid a Inse rvic e C re d it	FL Sub je c t	NBPTS
ｒｕ＃Ｕｈｌｑｖｗｄｗｈｇ＃
					Num b e r o f Po ints	Are a Te st	Ｆｈｕｗｌ￀ｆｄｗｈ

CG-10R RENEWAL APPLICATION FORM (2009)

TE A C H I N G E X P E R I E N C E R E C O R D (Sub stitute te a c hing e xp e rie nc e is no t a p p ro p ria te .)

Ｏｌｖｗ＃Ｗｈｄｆｋｌｑｊ＃Ｈ｛ｓｈｕｌｈｑｆｈ＃Ｖｌｑｆｈ＃Ｏｄｖｗ＃Ｆｈｕｗｌ￀ｆｄｗｈ＃Ｌｖｖｘｈｇ＃

L E G A L D I S C LO S U R E

Ｉｏｒｕｌｇｄ＃Ｏｄｚ＃ｕｈｔｘｌｕｈｖ＃｜ｒｘ＃ｗｒ＃ｓｕｒｙｌｇｈ＃ｄ＃＼ＨＶ＃ｒｕ＃ＱＲ＃ｄｑｖｚｈｕ＃ｗｒ＃ｗｋｈ＃ｔｘｈｖｗｌｒｑｖ＃ｚｌｗｋｌｑ＃ｗｋｈ＃Ｏｈｊｄｏ＃Ｇｌｖｆｏｒｖｘｕｈ＃ｖｈｆｗｌｒｑ＃ｒｉ＃｜ｒｘｕ＃ｄｓｓｏｌｆｄｗｌｒｑ／＃ｈｙｈｑ＃ｌｉ＃ｓｕｈｙｌｒｘｖｏ｜＃

ｖｘｅｐｌｗｗｈｇ１＃ Ｗｋｈ＃Ｄｉ￀ｇｄｙｌｗ＃ｖｈｆｗｌｒｑ＃ｐｘｖｗ＃ｅｈ＃ｆｒｐｓｏｈｗｈｇ＃ｚｌｗｋ＃｜ｒｘｕ＃ｖｌｊｑｄｗｘｕｈ＃ｅｒｗｋ＃ｗｌｐｈｖ＃ｌｗ＃ｒｆｆｘｕｖ＃ｚｌｗｋｌｑ＃ｗｋｈ＃ｉｒｕｐ／＃ｍｘｖｗ＃ｅｈｏｒｚ＃ｄｑｇ＃ｄｗ＃ｗｋｈ＃ｈｑｇ＃ｒｉ＃ｗｋｈ＃Ｏｈｊｄｏ＃

Disc lo sure Sup p le m e nt, fo r yo ur a p p lic a tio n to b e c o m p le te .

A F F I D A V I T

Ｌ／ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ／＃ｇｒ＃ｋｈｕｈｅ｜＃ｆｈｕｗｌｉ｜＃ｗｋｄｗ＃Ｌ＃ｖｘｅｖｆｕｌｅｈ＃ｗｒ＃ｄｑｇ＃ｚｌｏｏ＃ｘｓｋｒｏｇ＃ｗｋｈ＃ｓｕｌｑｆｌｓｏｈｖ＃ｌｑｆｒｕｓｒｕｄｗｈｇ＃ｌｑ＃

PRINT NAME

ｗｋｈ＃Ｆｒｑｖｗｌｗｘｗｌｒｑ＃＃ｒｉ＃ｗｋｈ＃Ｘｑｌｗｈｇ＃Ｖｗｄｗｈｖ＃ｒｉ＃Ｄｐｈｕｌｆｄ＃ｄｑｇ＃ｗｋｈ＃Ｆｒｑｖｗｌｗｘｗｌｒｑ＃ｒｉ＃ｗｋｈ＃Ｖｗｄｗｈ＃ｒｉ＃Ｉｏｒｕｌｇｄ１

Ｌ＃ｇｒ＃ｋｈｕｈｅ｜＃ｄｉｉｌｕｐ＃ｗｋｄｗ＃ｄｏｏ＃ｌｑｉｒｕｐｄｗｌｒｑ＃ｓｕｒｙｌｇｈｇ＃ｌｑ＃ｐ｜＃ｄｓｓｏｌｆｄｗｌｒｑ＃ｉｒｕ＃ｄ＃Ｉｏｒｕｌｇｄ＃Ｈｇｘｆｄｗｒｕﾷｖ＃Ｆｈｕｗｌｉｌｆｄｗｈ＃ｌｖ＃ｗｕｘｈ／＃ｄｆｆｘｕｄｗｈ／＃ｄｑｇ＃ｆｒｐｓｏｈｗｈ１

ＺＤＵＱＬＱＪ＝＃ ＃ ＪＬＹＬＱＪ＃ ＩＤＯＶＨ＃ ＬＱＩＲＵＰＤＷＬＲＱ＃ ＬＱ＃ ＲＵＧＨＵ＃ ＷＲ＃ ＲＥＷＤＬＱ＃ ＲＵ＃ ＵＨＱＨＺ＃ Ｄ＃ ＩＯＲＵＬＧＤ＃ ＨＧＸＦＤＷＲＵﾷＶ＃ ＦＨＵＷＬＩＬＦＤＷＨ＃ ＬＶ＃ Ｄ＃ ＦＵＬＰＬＱＤＯ＃ ＲＩＩＨＱＶＨ＃

UNDER FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RMATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.

ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃	ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
APPLICANT’S SIGNATURE	DATE

O F F I C I A L U S E O N LY

I N S E RV I C E C R E D I T

Ｌｑｖｈｕｙｌｆｈ＃Ｆｕｈｇｌｗ＃Ｆｒｐｓｏｈｗｈｇ＃Ｗｋｕｒｘｊｋ＃ｄｑ＃Ｄｓｓｕｒｙｈｇ＃Ｉｏｒｕｌｇｄ＃Ｐｄｖｗｈｕ＃Ｌｑｖｈｕｙｌｆｈ＃Ｓｕｒｊｕｄｐ＃
Ｑｄｐｈ＃ｒｉ＃Ｇｌｖｗｕｌｆｗ＃ｒｕ＃Ｖｆｋｒｒｏ＃Ｒｕｊｄｑｌ｝ｄｗｌｒｑ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃yxwvutsrpon
Ｌ＃ｋｈｕｈｅ｜＃ｙｈｕｌｉ｜＃ｗｋｄｗ＃ｗｋｈ＃ｄｓｓｏｌｆｄｑｗ＃ｖｄｗｌｖｉｄｆｗｒｕｌｏ｜＃ｓｄｕｗｌｆｌｓｄｗｈｇ＃ｌｑ＃ｄｑ＃ｄｓｓｕｒｙｈｇ＃Ｉｏｒｕｌｇｄ＃Ｐｄｖｗｈｕ＃Ｌｑｖｈｕｙｌｆｈ＃Ｓｕｒｊｕｄｐ＃ｄｑｇ＃ｈｄｕｑｈｇ＃ｂｂｂｂｂｂｂｂｂｂｓｒｌｑｗｖ＃ｗｒ＃
ｕｈｑｈｚ＃ｗｋｈ＃ｖｘｅｍｈｆｗｖ＃ｖｋｒｚｑ＃ｒｑ＃ｓｕｈｆｈｇｌｑｊ＃ｓｄｊｈ１
＃＃＃＃＃＃＃＃＃＃＃＃＃Ｖｗｄｕｗｌｑｊ＃Ｇｄｗｈ＝＃ｂｂｂｂｂ２ｂｂｂｂｂ２ｂｂｂｂｂｂ＃		Ｈｑｇｌｑｊ＃Ｇｄｗｈ＝＃ｂｂｂｂｂ２ｂｂｂｂｂ２ｂｂｂｂｂｂ＃	Inc lud e s “ Ba nke d ” Inse rvic e Po ints
			(CHECK HERE，＃
MM DD	YYYY	MM DD YYYY
ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃		ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃	ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
SIGNATURE OF AUTHORIZED	SCHOOL OFFICIAL	POSITION	DATE

CG-10R RENEWAL APPLICATION FORM (2009)

LE G A L D I S C LO S U R E ＃＋Ｉｏｒｕｌｇｄ＃Ｏｄｚ＃ｕｈｔｘｌｕｈｖ＃｜ｒｘ＃ｗｒ＃ｓｕｒｙｌｇｈ＃ｄ＃＼ＨＶ＃ｒｕ＃ＱＲ＃ｕｈｖｓｒｑｖｈ，＃

Ｄｉｗｈｕ＃ｄｑｖｚｈｕｌｑｊ＃ｈｄｆｋ＃ｒｉ＃ｗｋｈ＃ｉｒｏｏｒｚｌｑｊ＃ｔｘｈｖｗｌｒｑｖ／＃｜ｒｘ＃ｐｘｖｗ＃ｖｌｊｑ＃ｗｋｈ＃Ｄｉｉｌｇｄｙｌｗ＃ｗｒ＃ｆｒｐｓｏｈｗｈ＃ｗｋｌｖ＃ｖｈｆｗｌｒｑ＃ｒｉ＃｜ｒｘｕ＃ｄｓｓｏｌｆｄｗｌｒｑ１＃＃Ple a se re fe r to

ｗｋｈ＃ｌｑｖｗｕｘｆｗｌｒｑｖ＃ｌｑ＃ｗｋｈ＃Ｏｈｊｄｏ＃Ｇｌｖｆｏｒｖｘｕｈ＃Ｖｘｓｓｏｈｐｈｑｗ＃ｒｑ＃ｗｋｈ＃ｕｈｙｈｕｖｈ＃ｖｌｇｈ＃ｒｉ＃ｗｋｌｖ＃ｓｄｊｈ＃ｉｒｕ＃ｄｇｇｌｗｌｒｑｄｏ＃ｌｑｉｒｕｐｄｗｌｒｑ＃ｕｈｊｄｕｇｌｑｊ＃ｗｋｌｖ＃ｖｈｆｗｌｒｑ＃ｒｉ＃ｗｋｈ＃

a p p lic a tio n fo rm .

SEA LED O R EXPUNG ED REC O RDS ＋Ｕｈｓｒｕｗ＃ＲＱＯ＼＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｕｈｆｒｕｇｖ＃ｌｑ＃ｗｋｌｖ＃ｖｈｆｗｌｒｑ，＃

Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .

	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｚｈｕｈ＃ｆｒｑｙｌｆｗｈｇ o f a c rim ina l o ffe nse ?
	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｚｈｕｈ＃ｉｒｘｑｇ＃ｊｘｌｏｗ｜ o f a c rim ina l o ffe nse ?
	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｋｄｇ＃ｄｇｍｘｇｌｆｄｗｌｒｑ＃ｚｌｗｋｋｈｏｇ o n a c rim ina l o ffe nse ?
	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｓｏｈｇ＃ｑｒｏｒ＃ｆｒｑｗｈｑｇｈｕｈ to a c rim ina l o ffe nse ?
	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｓｏｈｇ＃ｊｘｌｏｗ｜ to a c rim ina l o ffe nse ?
	YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｚｋｌｆｋ＃｜ｒｘ＃ｈｑｗｈｕｈｇ＃ｌｑｗｒ＃ｄ＃ｓｕｈｗｕｌｄｏ＃ｇｌｙｈｕｖｌｒｑ＃ｓｕｒｊｕｄｐ o r ｇｈｉｈｕｕｈｇ＃
			p ro se c utio n p ro g ra m re la te d to a c rim ina l o ffe nse ?
	YES	NO	Ｇｒ＃｜ｒｘ＃ｋｄｙｈ＃ｄ＃ｓｈｗｌｗｌｒｑ＃ｓｈｑｇｌｑｊ＃ｗｒ＃ｖｈｄｏ＃ｒｕ＃ｈ｛ｓｘｑｊｈ＃ｄｑ｜＃ｆｕｌｐｌｑｄｏ＃ｒｉｉｈｑｖｈ＃ｕｈｆｒｕｇＢ＃

SEA LED o r EXPUNG ED re c o rd s MUST BE REPO RTED＃ｓｘｕｖｘｄｑｗ＃ｗｒ＃ｖｖ１＃＜７６１３８；８＃ｄｑｇ＃＜７６１３８＜／＃Ｉｏｒｕｌｇｄ＃Ｖｗｄｗｘｗｈｖ１＃＃Ｋｒｚｈｙｈｕ／＃ｈ｛ｌｖｗｈｑｆｈ＃ｒｉ＃ｖｘｆｋ＃ｕｈｆｒｕｇｖ＃

WILL NO T BE DISC LO SED＃ｑｒｕ＃ｐｄｇｈ＃ｓｄｕｗ＃ｒｉ＃｜ｒｘｕ＃ｆｈｕｗｌｉｌｆｄｗｌｒｑ＃ｉｌｏｈ＃ｚｋｌｆｋ＃ｌｖ＃ｓｘｅｏｌｆ＃ｕｈｆｒｕｇ１

C RIMINA L O FFENSE REC O RD(S) ＋Ｕｈｓｒｕｗ＃ｄｑ｜＃ｕｈｆｒｕｇ＃ｒｗｋｈｕ＃ｗｋｄｑ＃ｖｈｄｏｈｇ＃ｒｕ＃ｈ｛ｓｘｑｊｈｇ＃ｌｑ＃ｗｋｌｖ＃ｖｈｆｗｌｒｑ１，

Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .

YES	NO	Ha ve yo u e ve r b e e n ｆｒｑｙｌｆｗｈｇ o f a c rim ina l o ffe nse ?
YES	NO	Ha ve yo u e ve r b e e n ｉｒｘｑｇ＃ｊｘｌｏｗ｜ o f a c rim ina l o ffe nse ?
YES	NO	Ｋｄｙｈ＃｜ｒｘ＃ｈｙｈｕ＃ｋｄｇ＃ｄｇｍｘｇｌｆｄｗｌｒｑ＃ｚｌｗｋｋｈｏｇ o n a c rim ina l o ffe nse ?
YES	NO	Ha ve yo u e ve r p le d ｑｒｏｒ＃ｆｒｑｗｈｑｇｈｕｈ to a c rim ina l o ffe nse ?
YES	NO	Ha ve yo u e ve r ｓｏｈｇ＃ｊｘｌｏｗ｜ to a c rim ina l o ffe nse ?
YES	NO	Ha ve yo u e ve r e nte re d into a ｓｕｈｗｕｌｄｏ＃ｇｌｙｈｕｖｌｒｑ＃ｓｕｒｊｕｄｐ o r ｇｈｉｈｕｕｈｇ＃ｓｕｒｖｈｆｘｗｌｒｑ＃ｓｕｒｊｕｄｐ re la te d to a c rim ina l o ffe nse ?
YES	NO	Ｄｕｈ＃ｗｋｈｕｈ＃ｆｘｕｕｈｑｗｏ｜＃ｆｋｄｕｊｈｖ＃ｓｈｑｇｌｑｊ a g a inst yo u fo r a ny c rim ina l o ffe nse ?

PRO FESSIO NA L LIC ENSE O R C ERTIFIC ATE SA NC TIO N(S)

Fo r e a c h o f the fo llo wing q ue stio ns, if yo ur a nswe r is YES, p le a se se le c t YES. O the rwise , se le c t NO .

Ｌｉ＃｜ｒｘ＃ｄｑｖｚｈｕｈｇ＃＼ＨＶ＃ｗｒ＃ｄｑ｜＃ｒｉ＃ｗｋｈ＃ｓｕｈｆｈｇｌｑｊ＃ｔｘｈｖｗｌｒｑｖ／＃｜ｒｘ＃ｐｘｖｗ＃ｓｕｒｙｌｇｈ＃ｇｈｗｄｌｏｈｇ＃ｆｒｐｓｏｈｗｈ＃ｌｑｉｒｕｐｄｗｌｒｑ＃ｉｒｕ＃ｈｄｆｋ a ffirm a tive re sp o nse in the Le g a l Ｇｌｖｆｏｒｖｘｕｈ＃Ｖｘｓｓｏｈｐｈｑｗ＃ｒｑ＃ｗｋｈ＃ｕｈｙｈｕｖｈ＃ｖｌｇｈ＃ｒｉ＃ｗｋｌｖ＃ｓｄｊｈ＃ｄｑｇ＃ｖｘｅｐｌｗ＃ｌｗ＃ｄｏｒｑｊ＃ｚｌｗｋ＃｜ｒｘｕ＃ｄｓｓｏｌｆｄｗｌｒｑ＃ｉｒｕｐ１＃＃

CG-10R RENEWAL APPLICATION FORM (2009) LEGAL DISCOLOSURE 1

L E G A L D I S C LO S U R E S U P P L E M E N T

Ｉｏｒｕｌｇｄ＃Ｏｄｚ＃ｕｈｔｘｌｕｈｖ＃｜ｒｘ＃ｗｒ＃ｓｕｒｙｌｇｈ＃ｄ＃＼ＨＶ＃ｒｕ＃ＱＲ＃ｄｑｖｚｈｕ＃ｗｒ＃ｗｋｈ＃ｔｘｈｖｗｌｒｑｖ＃ｚｌｗｋｌｑ＃ｗｋｈ＃Ｏｈｊｄｏ＃Ｇｌｖｆｏｒｖｘｕｈ＃ｖｈｆｗｌｒｑ＃ｒｉ＃｜ｒｘｕ＃ｄｓｓｏｌｆｄｗｌｒｑ／＃ｈｙｈｑ＃ｌｉ＃ｓｕｈｙｌｒｘｖｏ｜＃ ｖｘｅｐｌｗｗｈｇ１＃＃Ｌｉ＃｜ｒｘ＃ｄｑｖｚｈｕｈｇ＃＼ＨＶ＃ｗｒ＃ｄｑ｜＃ｔｘｈｖｗｌｒｑ＃ｌｑ＃ｗｋｈ＃Ｏｈｊｄｏ＃Ｇｌｖｆｏｒｖｘｕｈ＃ｖｈｆｗｌｒｑ＃ｒｑ＃ｗｋｈ＃ｄｓｓｏｌｆｄｗｌｒｑ＃ｉｒｕｐ／＃｜ｒｘ＃ｐｘｖｗ＃ｓｕｒｙｌｇｈ＃ｇｈｗｄｌｏｈｇ＃ｆｒｐｓｏｈｗｈ＃

ｌｑｉｒｕｐｄｗｌｒｑ＃ｉｒｕ＃ｈｄｆｋ＃ｄｉｉｌｕｐｄｗｌｙｈ＃ｕｈｖｓｒｑｖｈ＃ｚｌｗｋｌｑ＃ｗｋｈ＃ｆｒｕｕｈｖｓｒｑｇｌｑｊ＃ｖｈｆｗｌｒｑ＃ｌｑ＃ｗｋｌｖ＃Ｏｈｊｄｏ＃Ｇｌｖｆｏｒｖｘｕｈ＃Ｖｘｓｓｏｈｐｈｑｗ１＃

＼ｒｘ＃ｄｕｈ＃ｑｒｗ＃ｕｈｔｘｌｕｈｇ＃ｗｒ＃ｄｆｎｑｒｚｏｈｇｊｈ＃ｐｌｑｒｕ＃ｗｕｄyxwvutsrpoｉｉｌｆ＃ｙｌｒｏｄｗｌｒｑｖ１＃＃Ｗｋｈ＃ｆｕｌｐｌｑｄｏ＃ｒｉｉｈｑｖｈ＃ｒｉ＃Ｇｕｌｙｌｑｊ＃Ｘｑｇｈｕ＃ｗｋｈ＃Ｌｑｉｏｘｈｑｆｈ＃＋ＧＸＬ，＃ｒｕ＃Ｇｕｌｙｌｑｊ＃Ｚｋｌｏｈ＃Ｌｑｗｒ｛ｌｆｄｗｈｇ＃

＋ＧＺＬ，＃ｌｖ＃no t＃ｄ＃ｐｌｑｒｕ＃ｗｕｄｉｉｌｆ＃ｙｌｒｏｄｗｌｒｑ＃ｄｑｇ＃ｖｋｒｘｏｇ＃ｅｈ＃ｇｌｖｆｏｒｖｈｇ＃ｒｑ＃ｗｋｌｖ＃ｉｒｕｐ１＃zyxwvutsrqp Ｋｄｙｌｑｊ＃ｄ＃ｆｕｌｐｌｑｄｏ＃ｋｌｖｗｒｕ｜＃ｒｕ＃ｄｇｐｌｑｌｖｗｕｄｗｌｙｈ＃ｖｄｑｆｗｌｒｑ＃ｄｊｄｌｑｖｗ＃ｄ＃ｓｕｒｉｈｖｖｌｒｑｄｏ＃ｏｌｆｈｑｖｈ＃ｇｒｈｖ＃ｑｒｗ＃ｄｘｗｒｐｄｗｌｆｄｏｏ｜＃ｇｌｖｔｘｄｏｌｉ｜＃ｄ＃ｓｈｕｖｒｑ＃ｉｕｒｐ＃ｕｈｆｈｌｙｌｑｊ＃ｄ＃

Ｉｏｒｕｌｇｄ＃Ｈｇｘｆｄｗｒｕﾷｖ＃Ｆｈｕｗｌｉｌｆｄｗｈ／＃ｅｘｗ＃ｖｘｆｋ＃ｌｑｆｌｇｈｑｗｖ＃ｚｌｏｏ＃ｓｕｒｐｓｗ＃ｄ＃ｕｈｙｌｈｚ＃ｅ｜＃ｗｋｈ＃Ｒｉｉｌｆｈ＃ｒｉ＃Ｓｕｒｉｈｖｖｌｒｑｄｏ＃Ｓｕｄｆｗｌｆｈｖ＃Ｖｈｕｙｌｆｈｖ１＃＃

A p e rso n is ｌｑｈｏｌｊｌｅｏｈ＃ｉｒｕ＃ｈｇｘｆｄｗｒｕ＃ｆｈｕｗｌｉｌｆｄｗｌｒｑ＃ｌｉ＃ｗｋｈ＃ｓｈｕｖｒｑ＃ｋｄｖ＃ｅｈｈｑ＃ｆｒｑｙｌｆｗｈｇ＃ｒｉ＃ｄ＃ｇｌｖｔｘｄｏｌｉ｜ｌｑｊ＃ｒｉｉｈｑｖｈ＃a liste d in Se c tio n 1012.315 Flo rid a Sta tute s. Ple a se re fe to ｚｚｚ１ｐ｜ｉｏｒｕｌｇｄｗｈｄｆｋｈｕ１ｆｒm fo m o re info rm a tio n.

S E A L E D O R E X P U N G E D R E C O R D ( S )

Ｆｌｗ｜＃Ｚｋｈｕｈ＃Ｄｕｕｈｖｗｈｇ＃	Sta te	Da te o f A rre st		C ha rg e	Ple a	Disp o sitio n (o utc o m e )
C R I M I N A L O F F E N S E R E C O R D ( S )
Ｆｌｗ｜＃Ｚｋｈｕｈ＃Ｄｕｕｈｖｗｈｇ＃	Sta te	Da te o f A rre st		C ha rg e	Ple a	Disp o sitio n (o utc o m e )
P R O F E S S I O N A L L I C E N S E O R C E R T I F I C A TE S A N C T I O N ( S )
Ｖｗｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃		＼ｈｄｕ＝＃ ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃＃		Ｏｌｆｈｑｖｈ＃ｒｕ＃Ｆｈｕｗｌｉｌｆｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
Ｌｖｖｘｌｑｊ＃Ｄｊｈｑｆ｜＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃				Ｖｄｑｆｗｌｒｑ＃ｄｑｇ＃Ｕｈｄｖｒｑ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
Ｖｗｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃		＼ｈｄｕ＝＃ ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃＃		Ｏｌｆｈｑｖｈ＃ｒｕ＃Ｆｈｕｗｌｉｌｆｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
Ｌｖｖｘｌｑｊ＃Ｄｊｈｑｆ｜＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃				Ｖｄｑｆｗｌｒｑ＃ｄｑｇ＃Ｕｈｄｖｒｑ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
Ｖｗｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃		＼ｈｄｕ＝＃ ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃＃		Ｏｌｆｈｑｖｈ＃ｒｕ＃Ｆｈｕｗｌｉｌｆｄｗｈ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃
Ｌｖｖｘｌｑｊ＃Ｄｊｈｑｆ｜＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃				Ｖｄｑｆｗｌｒｑ＃ｄｑｇ＃Ｕｈｄｖｒｑ＝＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃

A F F I D A V I T

Ｌ＃ｇｒ＃ｋｈｕｈｅ｜＃ｄｉｉｌｕｐ＃ｅ｜＃ｐ｜＃ｖｌｊｑｄｗｘｕｈ＃ｗｋｄｗ＃ｄｏｏ＃ｌｑｉｒｕｐｄｗｌｒｑ＃ｓｕｒｙｌｇｈｇ＃ｌｑ＃ｗｋｌｖ＃ｄｓｓｏｌｆｄｗｌｒｑ＃ｖｈｆｗｌｒｑ＃ｄｑｇ＃ｖｘｓｓｏｈｐｈｑｗ＃ｌｖ＃ｗｕｘｈ／＃ｄｆｆｘｕｄｗｈ／＃ｄｑｇ＃ｆｒｐｓｏｈｗｈ１＃

ＺＤＵＱＬＱＪ＝＃ＪＬＹＬＱＪ＃ＩＤＯＶＨ＃ＬＱＩＲＵＰＤＷＬＲＱ＃ＬＱ＃ＲＵＧＨＵ＃ＷＲ＃ＲＥＷＤＬＱ＃ＲＵ＃ＵＨＱＨＺ＃Ｄ＃ＩＯＲＵＬＧＤ＃ＨＧＸＦＤＷＲＵﾷＶ＃ＦＨＵＷＬＩＬＦＤＷＨ＃ＬＶ＃Ｄ＃ＦＵＬＰＬＱＤＯ＃ＲＩＩＨＱＶＨ＃ＸＱＧＨＵ＃

FLO RIDA LAW. A NYO NE G IVING FA LSE INFO RMATIO N O N THIS A FFIDAVIT IS SUBJEC T TO C RIMINA L PRO SEC UTIO N, A S WELL A S DISC IPLINA RY AC TIO N BY THE EDUC ATIO N PRAC TIC ES C O MMISSIO N.

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APPLICANT’S SIGNATURE	DATE

CG-10R RENEWAL APPLICATION FORM (2009) LEGAL DISCOLOSURE 2