EmailMe Form - 2023 Co-Presenters

Presentation Title *

MAIN Speaker's Name *

First Last

FLORIDA STATE CONTINUING EDUCATION INSTRUCTOR CERTIFICATION QUESTIONNAIRE

Please indicate which of the following options best represents your current status as a Florida certified continuing education instructor. *

a) I am approved and certified

b) I have applied to present the topics indicated below and am awaiting approval

c) I am a DFS employee but will be presenting with a Florida approved instructor

d) I am not an approved instructor, but will be presenting with a Florida approved instructor

e) I have not yet applied

If you answered (a) above, please enter your instructor number.

SPEAKER INFORMATION

YOUR Name *

First Last

Company/Firm Name *

Your Professional Title/Position/Rank *

Business Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Email *

Business Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Background information:

Speakers submitting presentation proposals may be subject to a background search to confirm that there aren’t any issues that would disqualify them as a potential speaker.

Professional license number (if applicable)

Has an administrative action ever been taken against you for violation of Statutes or Rules in Florida or any other state? *

Yes

No

Have you ever had any license suspended or revoked, whether in Florida or any other state? *

Yes

No

Have you ever been convicted or plead nolo contendere to a crime involving moral turpitude? *

Yes

No

If you have any question as to whether a crime involves moral turpitude, please reference the Department's webpage for additional guidance at the following links:

http://www.myfloridacfo.com/division/agents/licensure/general/priorcrimhist.htm
http://www.myfloridacfo.com/division/agents/licensure/general/DisqualifyingPeriods.htm

Have you ever been convicted or plead nolo contendere to a felony? *

Yes

No

If you responded “Yes” to any of the four questions listed above, please elaborate in this section:

GRANT APPLICANTS

If you are a law enforcement official or state prosecutor, you may be eligible for one of a limited number of grants from FIFEC to attend the 2023 conference. Please indicate if you will be registering to attend the conference and applying for a grant.

Applying for a grant? *

Yes

No

DOCUMENT UPLOAD

Please use the following section to upload your Speaker's Agreement and resume or CV (Word .doc, .docx, or PDF only).

File Upload *

You can upload multiple items