Mask Waiver Application for Educational Facilities

2. 

3. For Office Use Only
   For Office Use Only

   For Office Use Only

5. Mask Waiver Application for Educational Facilities

7. Educational Facility Name or DBA

9. Educational Facility Owner

11. Educational Facility Owner Name

13. Address1

15. Address2

17. City

18. State

19. Zip

21. Date Educational Facility Opened
    Date Educational Facility Opened

23. State License Number (SUNBIZ)

25. CONTACT INFORMATION

27. Address1

29. Address2

31. City

32. State

33. Zip

35. Phone Number

37. Emergency Contact Phone

39. Email Address

41. Authorized Signee/Owner

43. Authorized Signee/Principle Owner

45. Phone Number

47. EDUCATIONAL FACILITY INFORMATION

49. Number of Employees

51. Number of Students

53. Square Footage of Educational Facility

55. Disclaimer
    Applicant must also provide a written summary of the processes, protocols and physical improvements made to reduce the risk of spread of the COVID-19 Coronavirus. Please provide images of the physical improvements as part of this application. By signing this application, the applicant is affirming that all information in this application is true and accurate.

    Applicant must also provide a written summary of the processes, protocols and physical improvements made to reduce the risk of spread of the COVID-19 Coronavirus. Please provide images of the physical improvements as part of this application. By signing this application, the applicant is affirming that all information in this application is true and accurate.

57. Image 1

58. Image 2

59. Image 3

60. Image 4

62. Image 5

63. Image 6

64. Image 7

65. Image 8

69. Applicants Signature

71. Date of Signature
    Date of Signature

73. On This Day Of:
    On This Day Of:

75. FOR OFFICE USE ONLY

    Notary Stamp and Signature

Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field