Get Application For Concurrent Intern License

This guide provides comprehensive instructions on how to fill out the Application for Concurrent Intern License online, ensuring that you complete the form accurately and efficiently. Follow the detailed steps outlined below to navigate through each section of the application.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to access the application form and open it in your chosen editor.
2. In Section 1, Personal Information, enter your first name, middle name (if applicable), last name, name suffix (if applicable), and birth date in the specified format (mm/dd/yyyy). Ensure all entries are clear and legible.
3. For Section 2, Residence Address, provide your full street address (P.O. boxes are not permitted), apartment number (if necessary), city, country, county, state, and zip code.
4. In Section 3, Preferred Mailing Address, check the box if your mailing address is the same as your residence address. If not, fill in the street address (or P.O. Box), city, state, and zip code.
5. In Section 4, Phone & Email, enter your email address and primary phone number, including the area code.
6. In Section 5, Other Licensure Information, answer the questions regarding any previous licenses or registrations you have held in Florida. If applicable, be prepared to submit an 'Other Licenses' form.
7. Section 6 addresses Adverse Licensing History Questions. Provide truthful answers regarding past disciplinary actions. If you answer 'YES,' you must submit an 'Adverse Licensing Action History Form.'
8. In Section 7, Criminal History Questions, disclose any relevant criminal history. A 'YES' response requires an accompanying 'Criminal History Form.'
9. Section 8 requests Prior Name Information. If you have ever legally changed your name or been known by another name, provide those details.
10. In Section 9, Education Requirement, confirm your educational background by checking the applicable boxes and providing details of your college or university education.
11. Section 10 asks about your completion of a communicable disease course. Fill in the required details if applicable.
12. In Section 11, provide information regarding your approved training facility for your internship, including the facility's name, address, phone number, and license number.
13. Section 12 requires the identification and signature of your supervising licensee(s). Ensure they sign in the appropriate sections.
14. In Section 15, Miscellaneous Matters, confirm your understanding of ongoing responsibilities as an intern and the requirements that come with the application.
15. Section 16, Applicant's Certification & Signature, requires your signature and the date. If applicable, provide the name and title of the authorized signatory.
16. Finally, complete Section 17 by providing your Social Security Number. This information is collected for identification and background check purposes.
17. After completing all sections, you can save your changes, download the document, print it, or share it as needed.

Start your application process online today by following the detailed instructions above.