Form Dfs K4 1023 – Fill Out and Use This PDF

THE DEPARTMENT OF FINANCIAL SERVICES

DIVISION OF THE STATE FIRE MARSHAL

APPLICATION FOR FIRESAFETY INSPECTOR I CERTIFICATION EXAMINATION

BUREAU OF FIRE STANDARDS & TRAINING

Please type or print legibly.

NAME: LAST	FIRST	MI			DATE OF BIRTH
			00000
HOME ADDRESS:	CITY	STATE			ZIP CODE
000-00-00000			(000) 000-0000
SOCIAL SECURITY NUMBER1			TELEPHONE NUMBER
			(000) 000-0000
FIRE DEPARTMENT (if employed)			TELEPHONE NUMBER

IN ORDER TO QUALIFY FOR FIRESAFETY INSPECTOR CERTIFICATION, ONE MUST BE IN COMPLIANCE WITH FLORIDA STATUTES. Section 633.081(2)(b) states: “Not have been found guilty of, or having pleaded guilty or nolo contendere to, a felony or a crime punishable by

imprisonment of 1 year or more under the law of the United States, or of any State thereof, which involves moral turpitude, without regard to whether a judgment of conviction has been entered by the court having jurisdiction of such cases.”

DOCUMENTATION OF SUCCESSFUL COMPLETION OF THE FOLLOWING 40-HOUR COURSES IS REQUIRED:

COURSE TITLE

TRAINING CENTER

DATES ATTENDED

1.BUILDING CONSTRUCTION

2.CODES AND STANDARDS

3.FIRE PREVENTION PRACTICES

4.PRIVATE FIRE PROTECTION SYSTEMS

5.BLUE PRINT READING & PLANS EXAM

ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE SPACE

YES NO

Have you enclosed the current application fee? (Please see fee information, form DFS-K4-1019 for instructions)

Have you enclosed documentation of completing the 40-hour courses listed above? (Certificate or official College Transcript)

Have you enclosed the required Fingerprint Card completely filled out? (Proper card is attached) Have you submitted the notarized Personal Inquiry Waiver form? (Form DFS-K3-1020 is attached) Have you submitted a copy of your High School Diploma?

NOTE: YOUR APPLICATION MUST BE RECEIVED AT LEAST 10 BUSINESS DAYS PRIOR TO THE TEST DATE. YOU WILL RECEIVE WRITTEN CONFIRMATION OF THE TEST SITE AND DATE YOU ARE SCHEDULED TO TEST AND MUST BRING YOUR CONFIRMATION NOTICE AND PHOTO I.D. TO THE TEST SITE ON THE TEST DATE ASSIGNED. INDICATE THE REGIONAL TEST SITE AND DATE YOU

WISH TO BE ASSIGNED, ALONG WITH A 2ND AND 3RD CHOICE:

TEST SITE:					TEST DATE:
2ND CHOICE:					3RD CHOICE:
		SIGNATURE OF APPLICANT						DATE

SUBMIT THIS APPLICATION, ALONG WITH THE REQUIRED DOCUMENTATION AND PROCESSING FEE, TO: BUREAU OF FIRE STANDARDS AND TRAINING, 11655 NW GAINESVILLE ROAD, OCALA, FLORIDA 34482-1486

PURSUANT TO THE PROVISIONS OF THE AMERICANS WITH DISABILITIES ACT, ANY PERSON NEEDING SPECIAL ACCOMODATIONS,

PLEASE ADVISE US AT LEAST SEVEN CALENDAR DAYS PRIOR TO TEST DATE BY CONTACTING OUR ADA COMPLIANCE OFFICER AT (352) 369-2800.

1Please note that the social security number is not required; however, if you provide it, it will greatly assist us in assisting you.

DFS-K4-1023 REV 12/02

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02 – 5004-F