Florida Department of Agriculture and Consumer Services ...

NICOLE "NIKKI" FRIED COMMISSIONER

Florida Department of Agriculture and Consumer Services Division of Licensing

SEAPORT SECURITY TRAINING CERTIFICATE OF COMPLETION

Chapters 311 and 493, Florida Statutes Post Office Box 9100sTallahassee, FL 32315-9100s(850) 245-5665



GENERAL INSTRUCTIONS

INSTRUCTIONS TO CLASS "DS" SCHOOLS OR TRAINING FACILITIES: TYPE or PRINT the student's information in the spaces provided below. Give the ORIGINAL certificate to the student upon completion of the Seaport Security Officer training conducted in accordance with section 311.121, Florida Statutes. Send a copy of the certificate with written notification that includes the student's name and Class "D" license number, confirming the student's successful completion of the training, to the Division of Licensing; P. O. Box 9100; Tallahassee, FL 32315-9100.

INSTRUCTIONS TO STUDENTS: Upon your successful completion of the training, the school that provided your training will notify the Division of Licensing. To obtain a revised Class "D" Security Officer license, send your written request for the license to the Division of Licensing; P. O. Box 9100; Tallahassee, FL 32315-9100 with a check or money order in the amount of $15.00 made payable to the Division of Licensing.

STUDENT INFORMATION

Name:

Class "D" License Number:

Date of Birth:

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mm dd yyyy

Social Security Number *:

ACKNOWLEDGMENT OF COMPLETION OF COURSE AND EXAMINATION REQUIREMENT This certificate is awarded to the student named above in recognition of that individual's having completed the follow course:

220 HOURS s INITIAL TRAINING 8 HOURS s ANNUAL TRAINING 20 HOURS s RECERTIFICATION TRAINING

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Date Training Completed (mm/dd/yyyy)

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Date Training Completed (mm/dd/yyyy)

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Date Training Completed (mm/dd/yyyy)

Print, Type, or Stamp Name of Instructor

Class "D" License Number (if applicable)

Signature of Instructor

Date Signed

Name of Class "DS" School or Training Facility

Class "DS" License Number

* Sections 493.6105, 493.6304, and 493.6406, Florida Statutes (F. S.), in conjunction with section 119.071(5) (a) 2, F. S., mandates that the Department of Agriculture and Consumer Services, Division of Licensing, obtain social security numbers from applicants. Applicant social security numbers are maintained and used by the Division of Licensing for identification purposes, to prevent misidentification, and to facilitate the approval process by the Division. The Department of Agriculture and Consumer Services, Division of Licensing, will not disclose an applicant's social security number without consent of the applicant to anyone outside of the Department of Agriculture and Consumer Services, Division of Licensing, or as required by law. [See Chapter 119, F. S., 15 U.S.C. ss. 1681 et seq., 15 U.S.C. ss. 6801 et seq., 18 U.S.C. ss. 2721 et seq., Pub. L. No. 107-56 (USA Patriot Act of 2001), and Presidential Executive Order 13224.]

DACS-16059 Rev. 04/12 Page 1 of 1

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