DCF Privilege and Certification System (DEV)

User Registration

Provider Registration

Submission

Please correct the following errors:

First Name

Last Name

Position

Phone

County

I am the

Type of Organization

Federal Employer ID

Social Security Number

The Organization you requested has not been registered. Please enter the details for this organization so it can be registered upon approval.

Is this your Organization

Name of Organization as Registered with Secretary of State

Doing Business As-As Registered with Secretary of State

Other Names (if applicable)

Florida Business Registration

Is a non-profit organization?

Is a subsidiary of another organization?

Has the Organization been granted tax-exempt status by the IRS?

If yes, under what section is the federal code? Example: 501(C)

Primary DCF Program

Administrative Office Physical Address

Address Line 1

Address Line 2 (Optional)

City

State

Zip Code

Is Administrative address same as mailing address

Administrative Office Mailing Address

Address Line 1

Address Line 2 (Optional)

City

State

Zip Code

Action	Contact Type	Contact Info	Contact Description

Name of the Parent Organization

Contact Person's Name

Position Title

Phone Number

Address 1

Address 2

City

State

Zip

You are accessing a State of Florida information system. By submitting your registration request, you are certifying that the information you have provided is accurate and that you have a legitimate business purpose for requesting system access. Unauthorized use of the system is prohibited and is subject to criminal and civil penalties.

Please double-check the accuracy of the email address entered. We will use this in future communications with you. Following submission, you should receive an email verifying your registration has been received and is being reviewed for approval. Should you not receive this email within 24 hours, please check your SPAM folder, then contact DCF via TBD to request an updated status.

Find a Provider

Find a Provider

Administrative Office Physical Address

Administrative Office Mailing Address