CERTIFYING AGENT REGISTRATION FORM

CERTIFYING AGENT REGISTRATION FORM

For the Florida Green Home Designation Program
To register with the Florida Green Building Coalition (FGBC) as a Certifying Agent for the Florida Green Home Designation Program, please follow the instructions below.
INSTRUCTIONS
1. Complete the form in its entirety, including signing the affidavit
2. Provide your contact information that is most appropriate for FGBC communications
3. Pay the appropriate fees: $50; All FGBC Certifying Agents are required to be members of FGBC. Submit the FGBC membership application with your registration if you are not currently an FGBC member.
4. Send application package to Email: info@FloridaGreenBuilding.org
Are you currently a member of FGBC*

YesNo
FGBC Member ID
Date You Completed the Florida Green Home Designation Course*

MonthDayYear
Do you want your contact information to appear in the FGBC Certifying Agent Online Directory*

YesNO
Mr./Mrs/Ms
Name*

First NameLast Name
Nickname
Title/Occupation
Employer
Years Employed
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Cell
Email*
example@example.com
Have you ever had a professional designation revoked by a certification entity?*

YesNo
If you answered Yes to the above, please explain.
Completed Requirements

One year experience in the home building industry14 hours of Green Home Construction EducationSuccessful completion of two-day Florida Green Home Certification Training and exams
AFFIDAVIT
I have read and understand all provisions set forth in the Florida Green Home Designation Standard document and the Code of Professional Conduct. I agree to comply with all such provisions and understand that the provisions may change as time progresses. I pledge to maintain a working knowledge of the basis for the Florida Green Home Designation, and the documents used for certification including the Florida Green Home Standard Polices, Checklist and Reference Guide. I agree to report each certified Green Home to the Florida Green Building Coalition. I understand that this registration is good for one year and that I must continue to register each year to maintain good standing.
Signature of Certifying Agent*
PAYMENT INFORMATION:

Make checks payable to Florida Green Building Coalition or “FGBC” or pay online on at: https://form.jotform.com/13213329711

222 2nd Street North, St. Petersburg, FL 33701

CERTIFYING AGENT REGISTRATION FORM

INSTRUCTIONS

AFFIDAVIT

MINIMUM REQUIREMENTS TO BECOME AN FGBC CERTIFYING AGENT

REQUIREMENT # 1

REQUIREMENT # 2

REQUIREMENT # 3