
County Zip Code
Program Mailing Address, if different
City
Fax No.Telephone No.
APPLICANT INFORMATION (Applicant is the person with authority to request certification.)
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 for
Applicant's Mailing Address
Owner
Designated Representative (Applicable to corporations and partnerships only.)
Check One:
City County Zip Code
Email Address
DAY TIME
Change of Ownership
Change of Address
Fax No. Email Address
List locations, day, and time for group(s). For first-time applicants, list proposed schedule
Change of Director
Judicial Circuit ServedProgram Street Address (do not enter P.O. Box) If more than one location, attach additional sheet(s).
City
GROUP(S) SCHEDULE
County Zip Code Number of Locations within Circuit
Telephone No.
For initial application, attach cop
of resume and CF 1649D, Declaration of Good Moral Character for
Professional License No. (if applicable)
STREET ADDRESS, CITY, COUNTY
FACILITATOR INFORMATION (Attach additional sheets if needed.)
Professional License No. (if applicable)
Name First Middle Last Professional License No. (if applicable)
Name First Middle Last Professional License No. (if applicable)
Name of Director First Middle Last
Check Appropriate Box(es)
APPLICATION FOR CERTIFICATION
BATTERER INTERVENTION PROGRAM
Name of Program as it is to appear on certification
PROGRAM INFORMATION
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.
PLEASE TYPE OR PRINT LEGIBLY
New - $300
Renewal - $150
Program ID (Not required for new applications)
Position/TitleName of Applicant First Middle Last
Fax No. Email Address
ll facilitators must be approved by the department. For each, attach college transcript, training certificates, current resume and CF 1649D, Declaration of Good Moral Condu
form. Attachments are not re
uired for
reviousl
a
roved facilitators on renewal a
lications
but must be maintained in
ersonnel file
Name First Middle Last
Professional License No. (if applicable)
City County Zip Code
Name First Middle Last
Telephone No.
CF 831, January 2007
Authority: ss. 741.325-327, F.S., Chap. 65H-2, FAC
1 of 2 Office of Domestic Violence Program