DIVISION OF STATE FIRE MARSHAL
BUREAU OF FIRE STANDARDS AND TRAINING
PERSONAL INQUIRY WAIVER
APPLICANT'S NAME___________________________________________________________________
DATE OF BIRTH _________________ SOCIAL SECURITY # _________________________________
ADDRESS ___________________________________________________________________________
STREET CITY STATE ZIP
I respectfully request and authorize you to furnish the Division of State Fire Marshal, Bureau of Fire Standards and Training, any and all information that you may have concerning my work record, school record, military record, and moral character. Please include any and all information of a confidential or privileged nature, and photostats of same if requested. This information is to be used by the Bureau of Fire Standards and Training in determining my qualifications and fitness for certification as a firefighter, firesafety inspector, or other competency certification in the State of Florida.
_________________________________
SIGNATURE OF APPLICANT
Please note that the social security number is not required; however, if you provide it, it will greatly assist us in assisting you.
STATE OF FLORIDA
COUNTY OF ______________________________________
On _____________________, __________, _______________________________________ personally
(month and day) (year) (Applicant’s Name)
appeared before me and, __________ who is personally known to me, or __________ who has provided ______________________________________ as identification.
_________________________________
Notary Public Signature
Commission expires: _________________
PLEASE AFFIX SEAL ABOVE
DI4-1020 REVISED 03/01 MP