Get Homemaker Companion Services Application For Registration - Fdhc State Fl

The Homemaker Companion Services Application For Registration is a crucial document for organizations providing homemaker and companion services in Florida. This guide will assist you in completing the application accurately and effectively using an online format.

Follow the steps to fill out your application smoothly.

1. Press the ‘Get Form’ button to obtain the application form and open it in your preferred document editor.
2. Start by providing the name of your homemaker companion service in the designated field. If the name is fictitious, mark 'yes' and ensure that it is registered with the Department of State.
3. Fill out the business identification section with the physical address, mailing address, contact numbers, and email addresses. If they are the same, utilize the option provided to indicate this.
4. Indicate the type of application you are completing (Initial Registration, Renewal Registration, Change of Ownership) by marking the appropriate box and entering the corresponding registration fee.
5. Complete the ownership section by entering the ownership entity's name and Federal Employer Identification Number (EIN). Ensure no Social Security numbers are included.
6. List individuals or entities with a 5% or greater financial interest in your business and provide requested details.
7. Disclose the names of officers and board members associated with your organization, including their titles and contact numbers.
8. Answer the criminal conviction section, providing information if any listed individuals have criminal records as defined by state statutes.
9. Provide details about any terminations, exclusions, or withdrawals from program participation, if applicable.
10. State any interests in other health care providers and provide specific details, including names and license types.
11. Fill in the personnel information for all individuals managing the business, including titles and birthdates.
12. Complete the affidavit section, signing and dating it to affirm the truthfulness of the information provided in your application.
13. Finally, gather all required supporting documents, including application fees, and submit everything to the designated address. Remember to attach copies of your print advertising.

Begin completing your document online today to ensure timely registration.