Individual Information |
(Blue = Required fields) |
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Last Name |
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First Name |
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Middle Name |
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Suffix (Jr, III...) |
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Title |
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Mailing Address |
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City |
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State |
(Select One) Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana
Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
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Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Outside
the United States Pennsylvania Rhode Island South Carolina South Dakota
Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Wyoming |
Zip |
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County |
(Select One) Alachua Baker Bay Bradford Brevard Broward Calhoun
Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler
Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando
Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette
Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe
Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk
Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee
Taylor Union Volusia Wakulla Walton Washington * Out of Florida |
Country |
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Primary Phone |
Ext. |
Email |
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Web Address |
http:// |
Fax |
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Business Information: (The following information is only
required if different from your individual information.) |
Business/Firm Name |
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Email |
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Fax |
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Businnes Location Address |
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City |
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State |
(Select One) Alabama Alaska Arizona Arkansas California Colorado Connecticut
Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana
Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota
Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New
Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Outside
the United States Pennsylvania Rhode Island South Carolina South Dakota
Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Wyoming |
Zip |
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County |
(Select One) Alachua Baker Bay Bradford Brevard Broward Calhoun
Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler
Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando
Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette
Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe
Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk
Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee
Taylor Union Volusia Wakulla Walton Washington * Out of Florida |
Country |
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Additional Contact Information |
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Alternate Phone |
Ext. |
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Subject/Trade Area: (Select as many as apply) |
Accessibility |
Administration |
Building – Commercial |
Building – Residential |
Building – Special Occupancy |
Commercial Pool/Spa |
Electrical - Commercial |
Electrical - Residential |
Existing Building Code |
Fire |
Fuel/Gas |
Mechanical |
Other |
Plumbing |
Pollutant Storage System |
Residential Pool/Spa |
Roofing |
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Accreditor Qualifications: (Select one or more qualifications) |
Any person with a minimum four year college or graduate degree
within the field of study in which the Accreditor will be working.
Degree:
A person who is professionally licensed within the technical field with
which they will be accrediting and have a minimum of five years experience
in that field.
A substantially qualified authority within their field of relevant expertise. |
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Supporting Documentation: |
Detailed Resume of the Accreditor Michael
Rimoldi resume (2).pdf |
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Evaluation Process Flowchart of Processes/Timelines: |
Describe how you intend to evaluate courses to ensure 100%
compliance with the most current edition of the Florida Building Code and
its latest amendments?
Course
evaluation.pdf |
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Background Information: |
Is applicant approved as a provider by any board within DBPR
to provide continuing education?
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If yes, Board (Select One) Asbestos Board of Architecture
and Interior Design Board of Landscape Architecture Board of Surveyors
and Mappers Building Code Administrators and Inspectors Board Construction
Industry Licensing Board Electrical Contractors Licensing Board |
DBPR Provider Number |
Has any license, registration or permit to practice any regulated
profession, occupation, vocation or business been revoked, annulled, suspended,
relinquished, surrendered, or withdrawn in Florida or in any other jusrisdiction,
or is any such proceeding or investigation now pending?
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If yes, please download and complete Form 0060-1 and then |
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Certification Statements: |
I agree that payment for accreditation services will be rendered
by the Training Provider requesting services directly to the Accreditor
offline. |
I agree to comply with the Florida Building Commission requirement
that this course update take no more than 30 days for courses up
to 8 credit hours, and 45 days for courses in excess of 8 credit
hours. |
I hereby certify that all statements made on this application are
true and correct. I agree and understand that any misrepresentations
of material facts will result in revocation of this approval. |
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