DCF Background Screening
Intent to Apply for an Exemption from Disqualification Form

All Fields are required and denoted by *

REQUESTOR INFORMATION Last Name:* First Name:* Date of Birth:* SSN:* Phone:* Email:* Street Address:* City:* State:* Zip Code:*

FACILITY / CERTIFICATION BOARD INFORMATION Name of the facility you are applying to work for, or Certification Board where you have applied:* What type of a facility is this:* What role are you applying for:*

QUESTIONS

Prior to proceeding with this intent to apply for an exemption from disqualification, you must verify you understand the following information by checking the box next to each statement, sign and date this form

Three years or more have passed since I have been released from prison, parole or other criminal-related supervision that had been court ordered for a disqualifying felony criminal offense.* I am not under any type of criminal-related supervision that has been court-ordered due to a disqualifying misdemeanor criminal offense.* Any and all outstanding court-ordered costs or fees associated with my criminal history have been paid in full and I do not owe restitution, public defender or other court costs.* I am not designated as a sexual predator, sexual offender, or career offender.* I am formally requesting that the Department, in accordance with the provisions of Chapters 393, 408 and 435, Florida Statutes, provide me with an Exemption Review.* I understand that I must provide clear and convincing evidence to support a reasonable belief that I am of good moral character and that I pose no danger to the health or safety of children, persons with developmental disabilities, or vulnerable adults.* I understand that the decision of the Department of Children and Families or the Agency for Persons with Disabilities regarding this Exemption may be contested through a hearing under the provisions of Chapter 120, F.S.* I understand any person that knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree.*

By clicking submit you agree you are electronically signing and dating this form and submitting this form electronically to the department

DCF Background ScreeningIntent to Apply for an Exemption from Disqualification Form

DCF Background Screening
Intent to Apply for an Exemption from Disqualification Form