PRIVATE PROVIDER Registration Application

The City of Ocoee requires registration for all Private Providers before commencing work. Private Providers are responsible for keeping registration records current.

After you create and activate your account, you will be prompted to upload your Private Provider registration documents: List of Duly Authorized Representatives, Certificate of Insurance for Professional Liability, and Workers Compensation (optional).

Your email must be valid in order to activate your account. Your login name will be your Qualifier email address!

* all fields are required unless noted

Firm Information

* Name of Firm:
* Business Address:
Address Line 2:
* City:
* State:
* Zip Code:
* Phone Number:
Fax Number:
* Email:
* Federal Employer Identification Number (FEIN):

PRIVATE PROVIDER

* Private Provider Name: First: Last:
* Private Provider License Number:

PRIVATE PROVIDER QUALIFIER

* Name of Qualifier(s): First: Last:
* Phone Number:
* Email: (this will be your login name)
* Confirm Email:
* Certificate Holder’s Signature: (type full legal name as electronic signature)

Account Security

* Password:
* Confirm Password:
* Security Question:
* Security Answer:

I, _______________________________________, the Private Provider, do hereby affirm that the Duly Authorized Representatives listed are my employees, as required by Florida Statute 553.791 and are entitled to receive unemployment compensation benefits under Chapter 443.