Application to Become an Authorized Electronic Filing System Agent and Change of Certified Service Provider

Becoming an authorized as an electronic filing system agent in the State of Florida requires the use of the following application form. Complete the application and submit it along with any required information.

Extracted Text for Proper Search

 	
 
 
 
STATE OF FLORIDA 
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES - DIVISION OF MOTORIST SERVICES 
2900 APALACHEE PARKWAY, NEIL KIRKMAN BUILDING - TALLAHASSEE, FL 32399-0610	
 	
APPLICATION TO BECOME AN AUTHORIZED ELECTRONIC FILING SYSTEM AGENT / 
CHANGE OF CERTIFIED SERVICE PROVIDER 	
 
Check One: 	 	DMS USE ONLY 	
  Pursuant to section 320.03(10), Florida Statutes, I hereby make application to become 
authorized to process title and registration transactions using the Electronic Filing System. 
  I hereby request to change Certified Service Providers. 
Name of Entity / Business:  
Mailing address:  City:  State:  Zip: 
Physical Address:  City:  State:  Zip: 
Dealer License Number:                                                           If licensed as a motor vehicle, mobile home or recreational vehicle dealer. 
County where physically located:  Appointing County where agent will process transactions: 
If appointing county is different than where agent is physically located signature of the appointing Tax Collector is required. 
 
 _________________________________________                                                                                                  
Signature of Appointing Tax Collector  
Business Telephone Number:  Cell Number: 
E-mail Address: 
Owner / Partner / Principal Name(s): 
1. 
2. 
3. 
Certified Service Provider: (enter name of CSP) 
Applicant must have entered into a contract with a certified service provider prior to applying to become an EFS agent.  
If applicant is changing Certified Service Providers all pending or suspended transactions with the previous provider must be complete, 
a contract signed with the new certified service provider and notification to the state prior to using the new provider’s services.	
 	
  	All principals and prospective users have undergone a criminal background check	 	
  	Indicia shall be secure and in a locked area during non-business hours or when not being used.	 	 I certify that the entity above meets the requirements to become an authorized electronic filing system (EFS) agent.   
The entity will abide by all laws, rules, procedures and contractual obligations required as an EFS agent.  All principals and authorized 
users have undergone a criminal background check prior to having access to the EFS and indicia as provided by the Tax Collector.  All 
indicia will be secure and in a locked area during non-business hours or during non-use and I understand that I am responsible for any 
unaccounted inventory.  I further certify that all applicable inquiry fees will be paid to the state and that disclosures for EFS fees as 
required by rule will be made to prospective buyers.  I will ensure that all title and registration transactions are done in accordance with 
laws and Department procedure.  I further certify that state and county fees collected will be remitted electronically in accordance with 
state law.  I understand that failure to comply with any laws, rules or contractual terms shall be grounds for the Department to revoke 
my authorization to use the EFS. 
 
The applicant agrees to comply with section 119.0712 (2), Florida Statutes, and the Federal Driver’s Privacy Protection Act (18 U. S. C. 
§ 2721 et seq.).  The applicant agrees that all personal information governed by these statutes will be used or redisclosed by the 
applicant only as permitted by these statutes.  Any use or redisclosure of such personal information by the applicant except as 
permitted by these statutes will result in DHSMV revoking applicant’s ability to use the system.   
 
Under penalty of perjury, I do swear and affirm that the information contained in this application is true and correct and that applicant 
will abide by all laws of Florida and all applicable rules, policies and procedures of the Department of Highway Safety and Motor 
Vehicles. 
 
Signature of owner or principal: _______________________________________________  Date: __________________	 	
 
Rules 15C-18.004(1)(d).  15C-18.006(4), FAC 
 HSMV 82083 S (Rev. 08/11)