Agency/Facility Name 

Mailing Address

City    Zip    County

Physical Address (if different from above) 

City 

Does your agency/facility have a web-site? 

Chief Executive Officer      Email 

Phone   Fax

Accreditation Manager      Email 

Phone   Fax

Authorized Certified Correctional Officers        Authorized Civilian Support 

Total Authorized Inmate Beds

Our agency/facility is seeking (Pick one):   Initial Accreditation     Reaccreditation

Does your agency/facilitiy have a copy of the Current Florida Corrections Accreditation Standards Manual?    Yes      No

Please check chapters below which you feel are not applicable to your agency:

Are you currently Accredited?    Yes      No         

If yes,  By Whom           Date Accreditation Awarded

Are you currently under an Accreditation Contract?    Yes      No

If yes,  By Whom       Proposed Date of Award

Total of all Jail Facilities operated by your Agency:

Please list all Jail Facilities you wish to be accredited through FCAC.