"*" indicates required fields

I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).
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I have been granted an Exemption from Disqualification through the Florida Department of Health.
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**A copy of the Exemption from Disqualification decision letter must be attached**
If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.
Screening conducted by:
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Attestation
Under penalty of perjury, I,
hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S.
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This field is for validation purposes and should be left unchanged.