Florida Cf 831 Form in PDF

Change of Director

PLEASE TYPE OR PRINT LEGIBLY

Instructions: This application must be completed for new certification as well as annual renewal by the owner of the program or in the case of a corporation or partnership, the designated representative of the owner. A separate application and fee must be submitted for each circuit. Mail the application with the application fee and required documents to the department at the address provided. Make checks payable to the Department of Children & Families. Renewal of certification is contingent upon completion of any corrective action imposed by the department. An incomplete application will not be accepted.

PROGRAM INFORMATION

Program ID (Not required for new applications)

Name of Program as it is to appear on certification

Program Mailing Address, if different

GROUP(S) SCHEDULE

List locations, day, and time for group(s). For first-time applicants, list proposed schedule

ONSITE DIRECTOR INFORMATION (If multiple sites with multiple directors, attach additional sheets.)

For initial application, attach copy of resume and CF 1649D, Declaration of Good Moral Character form

FACILITATOR INFORMATION (Attach additional sheets if needed.)

All facilitators must be approved by the department. For each, attach college transcript, training certificates, current resume and CF 1649D, Declaration of Good Moral Conduc form. Attachments are not required for previously approved facilitators on renewal applications, but must be maintained in personnel file.

APPLICANT INFORMATION (Applicant is the person with authority to request certification.)

For initial application attach copy of resume and CF 1649D, Declaration of Good Moral Character form

Applicant's Mailing Address

LEGAL OWNERSHIP OF BIP

Complete only one of the categories listed below.

INDIVIDUAL

For initial application attach copies of resume, all licenses and CF 1649D, Declaration for Good Moral Conduct form

Role in BIP (attach additional sheets if necessary):

CORPORATION (not-for-profit or for profit)

Attach certificate of status or acknowledgement letter of registration from the FL Dept. of State, and current list of directors with title, address and phone number. Failure by any corporation to comply with all requirements under Chapter 607, F.S., is grounds for rejection or suspension of certification.

Registered Name

Role in BIP (attach additional sheets if necessary):

PARTNERSHIP (limited or general)

Attach certificate of status or acknowledgement letter of registration from the FL Dept. of State, and a list of partners with title, address and phone number. Failure by any partnership to comply with all requirements under Chapter 620, F.S., is grounds for rejection or suspension of certification.

Registered Name

Role in BIP (attach additional sheets if necessary):

I declare that the named program in this application meets all standards for state certification as required by Chapter 65H-2, Florida Administrative Code and section 741.325, Florida Statutes. By submission of this application and upon approval by the Department of Children and Families, I agree to abide by all rules and statutes that apply to the operation of a certified batterer intervention program. I understand that any omissions, misstatements, or misrepresentations are grounds for rejection or suspension of certification. I understand that the certification fee is non-refundable and certification is for one year and non-transferable. I understand that knowingly making a false statement on this application constitutes a second- degree misdemeanor as provided in section 837.06, Florida Statutes. By signing this application, I am declaring that all the information given within this application is true and correct.

ATTACHMENT 1

ATTACHMENT 2

APPLICATION FOR CERTIFICATION

BATTERER INTERVENTION PROGRAM

FACILITATORS

Authority: ss. 741.325, 741.327, F.S., Chap. 65C-5, F.A.C.

PLEASE TYPE OR PRINT LEGIBLY

Instructions: Please list additional facilitators below.

FACILITATOR INFORMATION

All facilitators must be approved by the department. Attach copies of college transcripts, training certificates, current resume and DCF Form ___, Affidavit of Good Moral Conduct. Documents are not required for previously approved facilitators on renewal applications.