Form Center

2. Account Number
3. Effective Date
   Effective Date
5. First Name
6. Last Name
8. Address1
10. Address2
12. City
13. State
14. Zip
16. I certify that I am covered under the provisions of Florida Statute 119 for the reasons indicated below:

    1. I (am) (have been) a member of one of the classifications listed below; and/or
    2. My spouse (is) (was) a member of one of the classifications listed below; and/or
    3. Either of my parents (is) (was) a member of one of the classifications listed below.
18. Law Enforcement Officer, Correctional Officer, or Correctional Probation Officer
20. Juvenile Probation Officers, Juvenile Probation Supervisors, Detention Superintendents, Assistant Detention Superintendents, Juvenile Justice Detention Officers I and II, Juvenile Justice Detention Officer Supervisors, Juvenile Justice Residential Officers, Juvenile Justice Residential Officer Supervisors I and II, Juvenile Justice Counselors, Juvenile Justice Counselor Supervisors, human services counselor administrators, senior human services counselor administrators, rehabilitation therapists, and social services counselors of the Department of Juvenile Justice.
22. Employee of Department of Children and Family Services whose duties include the investigation of abuse, neglect, exploitation, fraud, theft, or other criminal activities
24. Personnel of the Department of Health whose duties are to support the investigation of child abuse or neglect, or result in, the determination or adjudication of eligibility for social security disability benefits, the investigation or prosecution of complaints filed against health care practitioners, or the inspection of health care practitioners or health care facilities licensed by the Department of Health
26. Investigators or Inspectors of the Department of Business and Professional Regulation
28. Personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement
30. County Tax Collectors
32. Firefighter certified in compliance with s. 633.35, F.S.
34. Justice of the Supreme Court, District Court of Appeals Judge, Circuit Court Judge, or County Court Judge
36. State Attorney, Assistance State Attorney, Statewide Prosecutor, or Assistance Statewide Prosecutor
38. Guardian Ad Litem, as defined in s. 39.820, F.S.
40. Public Defenders, Assistant Public Defenders, Criminal Conflict and Civil Regional Counsel, and Assistant Criminal Conflict and Civil Regional Counsel
42. Victim of Domestic Violence in compliance with s 741.30 and 741.316, F.S.
44. County and Municipal Code Inspector
46. Code Enforcement Officer, or Animal Control Officer
48. Veteran, as defined in s. 1.01(14), F.S.; in compliance with s. 296.09(1), F.S.
50. Human Resources, Labor Relations, or Employee Relations Directors, Assistant Directors, Manager, or Assistant Managers or any local government agency, or Water Management District whose duties include hiring and firing employees, labor contract negotiation, administration, or other personnel-related duties.
52. Signature*
    By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
53. Date
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field