FORM 500A-2008 INITIAL______________

Effective______________ Date____________

Rule 9B-60 RENEWAL____________

Date____________

APPLICATION

Florida Department of Community Affairs

Building Energy Rating System

Rater Certification

Name: __________________________________________________________________________

(Last) (First) (Middle)

Company Name: ____________________________________________________________ Work Address: ___________________________________________________________________ City, State, Zip: _____________________________________________________________ Provide Services to the following Counties: ____________________________________________

Work Phone: ( ) Work Fax: ( )____________________ Work E-Mail: _______________________________ Home Address: __________________________________________________________________ City, State, Zip: _________________________________________________________________ Home Phone: ( ) Home Fax: ( ) ___________________ Home E-Mail: ________________________________

Circle Preference for correspondence: (office) or (home)

Date of Birth: ______________________

Day/Month/Year

High Post

Education Completed: School College Graduate

Degree(s) & Major Course Work: __________________________________________ Other Training: _________________________________________________________________

CEU(s)

Other Special of Short Courses Completed:

Nature of Work Experience and Place of Employment

From To ____________________ From To _____________________ From To _____________________

Have you had previous experience performing Florida Energy Code (or other) compliance calculations for residential, commercial or public buildings?

If yes, explain: ____________________________________________________________________ State Date

Have you ever been convicted of a felony? Yes No

Please check which rater classification(s) you are applying for below:

Residential Building Residential Building Public/New Commercial Buildings

Class 1 Existing Commercial Buildings

Class 2

Class 3

If you are applying for Residential Class 1 or Class 2 Building Rater or Existing Commercial Building Rater, you must submit documentation that you posses the requirements for those certifications stated in Rule 9B-60.005(2)(b). This includes copies of letters from employers verifying the appropriate experience or copies of certificates of completion from the appropriate training programs attended.

Dates of Rater Exam Completion: _____________________________________

Application Fees

Initial Certification Annual Renewal

Residential Rater $150 $50

Commercial Rater $150 $50

__________________________________________ Signature Date

Return To:

Florida Energy Gauge Program

c/o Florida Solar Energy Center

1679 Clearlake Road

Cocoa, FL 32922-5703

(321) 638-1715