d 2723758 mateen
TRANSCRIPT
-
7/26/2019 D 2723758 Mateen
1/22
FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
MSIONOF LICENSING
'Post Office Box 6687 Tallahassee, FL 32314-6687 8 5 0 ~ - ~
Internet Address: bttp:lllicgweb.doacs.stateJl.us
fr lf:
c
c::: fl
Chapter
493
Florida Starutes fG ll W lE {[
CHARLES
H
BRONSON
COMMISSIONER
T01992101-1
o S P 72 7
DIVISION a
WE ST
PALP/LICENSING
EGIONAL
O ~ E A C H
rFICE
APPLICATION FOR SECURITY OFFICER LICENSE -CLASS D
Please read all instructions carefully BEFORE
YOU BEGIN.
To prevent unnecessary delays In the processing of your application,
PLACE
NUMBERS
LETTERS
INSIDE
BOXES AS
SHO'MI.
be
sure
to answer all questions and submit any necessary documentation.
APPLICANT INFORMATION
-If you are an allen, you inust
also
provide I
, your
Alien
Reglstratbn
Number.
L.
- L - - - ~ : = 1 : - : - : - - : : ~ -
M IUNG DDRESS
CONTINUED SUITE, BLDG., l
APT.,
ETC.
HOME PHONE NUMBER WORK PHONE NUMBER
\ 7 \ 1 \ z \ 4 \ a \ ~ o \ l h h \sl \ 1 \ 1 \ c . . l ~ \c..\1\ \-s\s
I
ACS.16007 1
0105
onnerty
LC2E004
-
7/26/2019 D 2723758 Mateen
2/22
SECTION II.
PRIOR
ADDRESS HISTORY
Please list all addresses where
you have lived
lor the pasts
YEARS. Begin with
your current address. II
more
space
is required.
you
may use
a
separate sheet
of paper.
S T R ~ ADDRESS
'to rJ W
'I over
c f
CITY
f
f6
5t
Gic..le
STATEj: (_
1 Y f ~ s
LENGTH
OF
TIME
AT THIS
ADDRESS
FROM:
01.
l QC..
TC'
l?rf: .,
MONTii
''
O ~
STREET ADDRESS
'+a..A4ra
L-N
kl.t
r-JU
CITY
STATE
IIP 'tJ 3
l oA
J f ' ( ~ f d t
IHONE
NUMBig
(172.-) G t / ~ J 7 o S
STREET ADDRESS jtl1
_Q.-d
, S T A T E , Z I ~ D E
~ r : > o . , 1 > 1 )
o
l P ~ < ~ . ~ -
. .
rWt< a. v
'
U),....
TLE
DATES OF EMPLOYMENT
C o r r ~ d 1
0 \ )_
\ c ~ k c ~
r
FROM:
I ~ I OC.
TO< d+
lo?
" ' ' ~
'' '
U M M ~ OF
JOB
DUTIES
-I-
. c.....
6J..rq
,.(-
( 1 \ . ~ e < : ;
'
NAME
OF E M P L O Y ~ r
Ga .-.
S '(' yta.._....-.tl,
NAME
F
EMPLOYER
p (,. -/ N\
I P ( 0 1E 7 4E h : 1 -
7_
S T A E J Z : _ A ~ E S S N W
P
.
[ 13' J
,
~ O C 6 ' : . /
,
{S
'
- ' '
- ~
SUMMARY OF JOB DUTIES
\JJ
'.\-c\-'
G
1 V'
-
7/26/2019 D 2723758 Mateen
4/22
SECTION
liV.
Ml LITARY HISTORY
Have you ever
served
in
the
armep fOrces? If YES, complete the following:
YES
ype of discharge
Date
of
Separation
SECTION V
CRIMINAL HISTORY
Have you ever been convicted or
had
adjudication withheld on any
felony or
misdemeanor in
any
jurisdiction?
Do
not include p rking or speeding violations).
If YES,
please provide
accurate
and
complete
information below
AND submit
certified
copies of
court
dispositions.
OvEs
~
r o l s l n ~ o t t o n
ot
anawere
or
folluro
to
provide certified
copies
of
court
dleposttlone may
result
In
tho
denial
of your application
DATE
OF
ARREST
COUNTY/STATE
CHARGES
DI8P081TION(8)
Are
you currently
on
parole, probation, deferred
prosecution, pre-trial Intervention,
or
any
ather form of state
OvEs
G iO
r
federal
supervision?
SECTION VII.
ALIASES
Have you
ever
been
known
by
a
name
other
than
the
one stated
on
the
front
page
of tl'is application?
This
includes married,
malden,
professional, alias, or
fictitious
names.)
If
YES, please list
those names below:
OvEs
o
IAME
NAME
IAME
NAf lE
I
SECTION VII.
PERSONAL HISTORY
a) Have you ever been adjudicated lncapacltated* under Chapter
744,
F. S., or similar laws of another state?
OYES
~ o{"Adjudicated incapacitated" means the court
has determined
you are
Incapable
of
taking care
of yourself}.
If
YES, lease
orovlde a certified coov of
the
court document restorlno caoaCitv.
b) Have you ever
been
involuntarily placed In a
treatment
facility for the mentally
Ill
under Chapter
394, F. S., or under
the
authority of slmllar laws of another stale?
If
YES, Please provide a certified copy of the
court document
restoring competency.
OvEs ~ o
c) Have you
ever
been
diagnosed
with
a mental
illness?
~
f
YES,
please provide a statement
from
a
psychiatrist or
psychologist licensed in Florida attesting that you are not
OvEs
currently s u f f ~ ~ ~ g from en Incapacitating mental illness
that
precludes you from performing
regulated
duties of an
unarmed securi officer.
d) Do you currently abuse any controlled substance?
QYES
G11o
e)
Do you
have
a history of controlled substance
abuse?
QYES
~
f YES,
please
submH evidence
of
successful
compleUon
of adrug
rehabilitation
program and three letters of reference,
one
of which should be from your sponsor in
the
rehabilitation
program.
f)
Do
you have a history of alcohol abuse?
QYES
e NO
f YES, please submit evidence of successful
completion
of an alcohol rehabilitation program and three leiters of
reference,
one of
which
should be
from your sponsor In the rehabilitation
program.
SECTION VIII.
TRAINING/EXPERIENCE
a)
Have you successfully completed the training required for licensure as asecurity officer as required by Section
493.6303 4
), F s ~
PLEAS :
BE
SURE
TO ATTACH A COPY OF YOUR CERTIACATE
OF COMPLET10N. ES
F a l l u r < ~ I O
oubmtt proof
oftralnlngwlll
reaultln unnecessary delay In the processing of
your
application.
ONO
b) Have you ever been licensed to
perform
security duties In Florida or in anyothar state?
~
f
YES, please
specify which
state
and the
period
of lime
during which
you were
licensed:
YES
STAVE: PERIOD OF LICENSURE:
c) Have you ever
had
a security license or
registration
revoked, suspended, or
otherwise acted
agalnsl (including probation,
QYES
~
ine,
reprimand,
or surrender of license) In a disciplinary proceeding in
any
state?
If
YES, please provide In the space below complete details
regarding
this
action,
including
the
state In which
the acllon
occurred, relevant dates, and circumstances.
-
7/26/2019 D 2723758 Mateen
5/22
SECTION IX. EXEMPTION FROM PUBLIC RECORDS DISCLOSURE
See Section IX of the Appficallon Instructions to detennlne
if
you qual'lfy for exemption
from
Public Records Disclosure.
0YES
0No
f you do not qualify for
the
exemption, proceed
to
Section
X.
If
you qualify for
the exemption, do
you
wish to have the Information kept confidential?
SECTION X. CITIZENSHIP
a)
Are you a citizen of
the
United States?
01.s 0NO
f
YES,
proceed to Section
XI
of the application form.
If
NO, you must answer question
(b)
below.
See
Section
of the APPUCATION INSTRUCTIONS for further detaHs.
b Are
you deemed a awful permanent resident allen by
the
Department of
Homeland Security,
United States
Citizenship
and Immigration Services (USCIS,
formerly
USINS) or have
you
been
OYES
0NO
ranted authority to
work by
the USC
IS?
If YES, you must submit a clear
and
legible
copy
of the documentation
issued
to
you
by the USC
IS.
If you are not a lawful permanent resident
alien
or do not possess valid work authorization,
you are not eligible for licensure.
SECTION XI. PERSONAL INQUIRY WAIVER AND NOTARIZATION STATEMENT
I certify thai Iunderstand that the Division of
Licensing
will conduct any Investigation deemed necessary to assure that 1have met all statutory
requirements
for
licensure.
I understand that
inquiry shall be
made regarding my
criminal
history and that subsequent Investigation
may
include my school records, employment history, financial recOrds, any history ofcontrolled substance or alootlol abuse, and my mental capacity.
1
hereby waive any provision
of aw
forbidding any
school
official, court,
pollee
agency, employer, finn
or
parson
from
diSclosing to
the Division
any
knowledge or infonnation concerning
me,
and
1 o
certffy
hall give permission
f t
such
entity to disclose any Information
and to
provide any
record requested concerning me to
the Division.
I also affirm that the information contained in this
application
and all attachments I
have
submitted
to be
trua and oorrect to the best of my
kno.DO.
The foregoing application was swom to (or affirmed} and subscribed before
me
this
. Q _ ~ d a y of
S-0-
' 20_Q_-:\.by:
""""'
_ c - < . _ _ ~
c
0---...S :>c.
. .
c ----10:
- - ~ , ~ ~ ~ - .
-
7/26/2019 D 2723758 Mateen
13/22
CIIARLES M. BRO'ISON
COMMISSIONER
Florida Department of Agriculture
and
Consumer Services
Division of Licensing
RENEWAL NOTICE
Chapter 493, Florida Statutes
Post Office
Box
9100 Tallahassee, FL 32315-9100 (850) 245-5691
Internet Address: httoHmylicensesite.com
DATE
PRINTED:
APR 17, 2011
LICENSE
#:
D
-27-23758
WILL
EXPIRE: SEP 14,
2011
llmllllllllllllllmiiiRIIIIIIIIIIIIIIIIIII
MATEEN OMAR
11161986
T036916515
4
90 NW
DOVER
CT
PORT
ST. LUCIE
FL
34983
om
m
il
lim 1m111m 1
nmnun1n
llllllim nmHllllllll
SECURITY
OFFICER
LICENSE RENEWAL
PLEASE
ALLOW
8-10 WEEKS FOR PROCESSING.
: ~ ' ( J ~ J :
uw;:
\
c:
:/\1\ c:: o:
:sru:
:Nci: 1\DDm:ss AND/OR MAiliNG Aoo;{r:ss?
The information
below
reflects residence address and
address on file with
the Division of licensing. If the informatio.n..lli_
. I
address
has
the correct information.
CURRENT
RESIDENCE
ADDRESS
490 NW
DOVER CT
PORT
ST. LUCIE, FL
34983
CURRENT
MAILING
ADDRESS
490
NW
DOVER CT
PORT ST.
LUCIE,
FL 34983
1 - - - - - ~ R C E S I D E N C E A D ~ D ~ R ~ E i S S S - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - p ; r o . ~ r u o ~ . - - - - - - - - - - - - - j
l \ 3 5 1 1 r -s-r
RESIDENCE ADDRESS CONTINUED
(SUITE, BLDG., APT., ETC.)
CITY
MAILING ADDRESS
MAILING ADDRESS CONTINUED
(SUITE, BLDG., APT., ETC.)
CITY
EMAIL ADDRESS
STATE ZIP CODE
STATE ZIP CODE
SU8MIT i ' i ~ i ~ . f- Ol.LOWING WITH YOUR
R i N ~ W A L A P P L I C A I I O N
I Y
> I J I I ~ < I ~ ; S I ( l i ~
Oi
' i l l : '
f ~ t ; ; . . :
' . W / \ 1 . / \ f ' P l . I C J \ 1 ' 1 0 ~ .
YOU AHE
CONFIHC.ilo\JG
YOUR CONTINUED ELIGIBILITY FOH
YHF. LICf:NSlO UNDER
1 ONE PASSPORTTYPE COLOR PHOTOGRAPH (See Reverse Side)
IF APPLICABLE:
3. YOU MAY RENEW YOUR LICENSE UP TO 3 MONTHS AFTER IT EXPIRES. IF YOUR RENEWAL
APPLICATION
IS
SUBMITTED AFTER THE EXPIRATION DATE OF YOUR LICENSE, BE SURE TO
INCLUDE THE LATE FEE IN THE AMOUNT
OF
............................................................................................................
4. IF YOUR LICENSE HAS BEEN EXPIRED FOR
3
MONTHS
OR
MORE. YOU MUST REAPPLY.
IT
IS
UNLAWFUL TO PERFORM REGULATED DUTIES WITH AN EXPIRED LICENSE
DACS-16010
Rev.
1 10
Page
1
of
2
45
45
-
7/26/2019 D 2723758 Mateen
14/22
Color Photograph Specifications (Passport Size Photo)
Photograph must show
the
subject in a frontal portrait (no hats,
no
sunglasses).
Photograph outer dimensions JD 1W be larger than 1 X w X 1 3/8 h.
Photograph must
be
color with a light colored background (no fancy backdrop, lettering, etc.).
Surface of
the
photograph must be glossy.
Photograph must not be stained, cracked or mutilated, and must lie
flat
Photographic image must
be
sharp
and
correctly exposed; photograph must not
be
retouched.
Photograph must not be pasted
on
cards or mounted
in
any
way.
One photograph every applicant must
be
submitted.
Photographs must
be
taken within six months
of
the application
date.
Snapshots, group pictures, or full-length portraits
will o21
be accepted.
To avoid mutilation of the photograph, lightly print your
name &
dale of birth
on
the back using a crayon or fell tip
pen.
Do
not use
glue
staples, or a paperclip
to
attach photograph to application.
Doing so may
cause damage
when mail is
sorted
by
the U.S. Post Office.
Do
not cut the photograph.
DACS-16010 Rev. 1/10
Page of 2
-
7/26/2019 D 2723758 Mateen
15/22
CHECK
OMAR
S MATEB
490 NW DOVER CT
PORT SAINT LUCIE, FL 34983
533
lJot T E R < W ~ t f t : O R I D A
SIA'fPJ: =S.
SUBMIT THE FOLLOWING WITH YOUR RENEWAL APPLICATION
1 ONE PASSPORT-TYPE COLOR PHOTOGRAPH SEE SPECIFICATIONS ON REVERSE
SID).
2.
A CHECK OR MONEY ORDER MADE
PAYABLE
TO THE FLORIDA DEPARTMENT OF AGRICULTUREAND CONSUMER
SERVICES IN THE AMOUNT OF
FE ARE NON REFUNDABLE.
IF APPLICABLE:
3. YOU MAY RENEW YOUR LICENSE UP TO 3 MONTHS AFTER IT. EXPIRES. IF YOUR RENEWAL APPLICATION IS
SUBMITTED AFTER THE EXPIRATION DATE OF YOUR LICENSE, BE SURE TO INCLUDE THE lATE FEE IN THE
AMOUNT
O
IF YOUR UCENSE HAS BEEN EXPIRED FOR 3 MONTHS OR MORE. YOU MUST REAPPLY. IT IS
UNlAWFUL
TO
PERFORM REGULATED DUTIES WITH AN EXPIRED LICENSE .
DACS-16010 Rev. 10112
Page
1
ol2
45
45
-
7/26/2019 D 2723758 Mateen
17/22
COLOR PHOTOGRAPH
SPECIFICATIONS
(PASSro
-
7/26/2019 D 2723758 Mateen
18/22
CHECK
-
7
J
. o.-
-
-
7/26/2019 D 2723758 Mateen
19/22
Florida Department of Agriculture and Consumer Services
Division of Licensing
ADAM
H. PUTNAM
COMMISSIONER
RENEWAL NOTICE
Chapter 493, Florida Statutes
Post Office Box 5767Tallahassee, FL
3 2 3 1 4 ~ 5 7 6 7 8 5 0 )
2455691
www.mylicensesite.com
DATE PRINTED: APR
19,
2015
LICENSE : D -27-23758
WILL
EXPIRE:
SEP 14 2015
MATEEN
OMAR
APT l07
111111
m
11161986
T069324058
2513 S 17TH
ST
FORT PIERCE,
FL 34982
mlll
~ l l l l l l l l l m 11111 1111111111111 IIIIIIIIIUIIIIIIIIIIIIIIIIIIWIIIIIIIIIIIIIII
SECURITY OFFICER LICENSE
RENEWAL
ALLOW 8-10
WEEKS FOR
PROCESSING.
FOR
CREDIT
CARD PAYMENT OPTION, VISIT
WWW.FRESHFROMFLORIDA.COM
AND
CLICK
'ONLINE
PAYMENTS.
.
__ ........
_
AVE"'fO\:
H i \ N 6 E O ~ t 0 \ : , 1 : C R i : S i C E N C E i - \ E l f r m : B G Q R
MAtL't..'GACDRS$1->-....-
~ - - . . . . -
-
The ihformatlon balo'.'J"teflecfu your'reside'hce addresS Snd your mailing address.on fite with the Division o Licensing.
"tfthe jUtormBt on ti
orn
lea@
t l J J ~ area
tlfMJ .. If your residence address
OR
your malting address has changed, please enter the correct information.
CURRENT RESIDENCE ADDRESS
CURRENT MAILING ADDRESS
2513
S
17TH
ST
2513
S
17TH ST
APT l07 ' APT l07
FORT
PIERCE,
FL 34982 FORT
PIERCE,
FL 34982
.
RESIDENCE ADDRESS
R -:: ,... r - 1 \ I .... ..
- JL.I
V
L.L
I
I I
I
I I
I
I
I
I I
I
I
I I
I
I I
I
I
I
I I
I
I
I
I
I I I I
AUG 19 Z015 ..J)a
RESIDENCE ADDRESS
CONTINUED SUITE, BUILDING. APT., ETC)
I I
I
I I
I
I I I I I I
I
I I
I
I I
I
I I I I
I
I I I I I I I
DIVISION OF LICENSING
WEST P.A M BEACH
CITY
STATE
ZIP CODE
R E G I O N A ~ p F F I C E
I I I I I I I I
I
I I I I I I I
I
I
I
I I I I I I I
I
w
I
I I I
1 I
I
I
I
MAILING ADDRESS
IF
DIFFERENT FROM ABOVE
I I
I
I
I I
I
I
I
I I I I
I
I I
I
I
I I
I
I
I I I I
I
I I
I I
MAILING ADDRESS
CONTINUED SUITE, BUILDING, APT.,
ETC)
I I I I I
I
I
I
IJJ
I I I I
I
I I
I
I I I I
I
I I I I I I II
CITY STATE
ZIP COQE
..
I
I I I I I I I I I
I
I I I I I I I I I I I I I I I I w
I
I I
I
I I
I
I
I
E-MAIL ADDRESS
I I
I
I
I
I
I
I
I I
I
I
I
I I
I
I
I I
I
I
I I I I
I
I I
I I
I I
I I
I I
I I
I
I
. BY
SUBMISSIONOF THE RENEWALAPPI:.lCAT ON.
YOU
ARE
CONfiRMING
YOUR
CONTINUED ELIGIBILITY
FO,R
THE LICENSE UNDER CHAPTER
493,
FLORIDA STAlUTES.
SUBMIT THE FOLLOWING WITH YOUR RENEWAL APPLICATION
1. ONE PASSPORT-TYPE COLOR PHOTOGRAPH
(SEE sPECIFICAnONS
ON
RE\IERSE SIDE).
2.
ACHECK OR MONEY ORDER MADE PAYABLE TO THE FLORIDA DEPARTMENT OF AGRICULTURE AND CONSU MER
SERVICES
IN
THE AMOUNT
OF
FEES
ARE
NON REFUNDABLE.
IF APPLICABLE:
3. YOU MAY RENEW YOUR LICENSE UP TO 3 MONTHS AFTER IT EXPIRES. IF YOUR RENEWAL APPLICATION IS
SUBMITTED AFTER THE EXPIRATION DATE OF YOUR LICENSE, BE SURE TO INCLUDE THE LATE FEE
IN
THE
AMOUNT OF
IF YOUR LICENSE HAS SEEN EXPIRED FOR 3 MONTHS OR MORE, YOU MUST REAPPLY.
PERFORM REGULATED DUTIES WITH AN EXPIRED LICENSE.
DACS-16010 Rev. 01/15
Page 1 of 2
IT IS UNLAWFUL
TO
45
45
I
I
-
7/26/2019 D 2723758 Mateen
20/22
OLOR PHOTOGRAPH
SPECIFICATIONS PASSPORT-SIZE PHaro
Your photograph must be:
> In color, non-retouched.
>
Printed on matte or glossy photo quality paper.
> 2 x2 inches 51 x
5 mm)
in size.
> Sized such that the head is between 1 inch and 1 3/8 inches
{between 25 and 35 mm) from the bottom
of
the chin to the top
of
the head.
Taken within the last6 months to reflect your current appearance.
Taken in front of a plain white or off-white background.
> Taken
in
full-face view directly facing the camera.
With a neutral facial expression and both eyes open.
> Taken in clothing that
you
normally wear
on
a daily basis:
Uniforms, clothing that looks like a uniform, and camouflage attire should not
be
worn in photos except in the case
of
religious attire
that is worn daily.
You
may only wear a hal
or
head covering i f you wear It daily for religious purposes. Your full face must be visible and your head
covering cannot obscure your hairline or cast shadows on your face.
Headphones, wireless hands-free devices
or
similar items are not acceptable in your photo.
f
you normally wear prescription glasses, a hearing device or similar articles, they may be worn for your photo. Glare on glasses
is not acceptable in your photo.
Dark glasses or non-prescription glasses with tinted lenses are not acceptable unless you need them for medical reasons
a
medical certificate may be required).
RETURN YOUR RENEWAL APPLICATION TO POST OFFICE BOX 5767, TALLAHASSEE, Fl. 32314-5767.
IF YOU
HAVE
ANY QUESTIONS, CONTACT THE PUBLIC INQUIRY SECTION [email protected] OR 850) 245-5691 .
FDACS-16010 Rev. 01/15
Page 2
of
2
-
7/26/2019 D 2723758 Mateen
21/22
HE K
RECEIVED
AUG 9 2 15 V f7
DIVISlON OF LICENSING
WEST P LM BE CH
REGION L OFFICE
- ~ - - - - '
-
1
I
-
7/26/2019 D 2723758 Mateen
22/22
.
RECEIVED
AUG
10
2015 v1J
DIVISION OF LICENSING
w ST
PALM BEACH
REGIONAL OFFICE
Photo
on
ile
..
---
........... . -
-
ssJ\r:\L ___...J.;=r__JTP - -