Free 44176.FH11 - Indiana

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APPLICATION FOR LICENSURE AS A REAL ESTATE SALESPERSON OR BROKER
State Form 44176 (R3 / 7-06)

Approved by State Board of Accounts, 2006 *Your Social Security number is being requested by this state agency in accordance with I.C. 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it. Social Security numbers are available to the Indiana Department of Revenue.

INDIANA REAL ESTATE COMMISSION PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3009 E-mail: [email protected] www.pla.IN.gov

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSED ISSUED (month, day, year) DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY PLEASE TYPE OR PRINT AND ANSWER ALL QUESTIONS.
License type applying for (please check one only) Are you applying via reciprocity?

Salesperson
Reciprocal state

Associate Broker

Independent Broker
Reciprocal license number

Principal Broker

Yes
Name (last, first, middle, maiden or previous) Date of birth (month, day, year)

No APPLICANT INFORMATION

Place of birth (city and state)

Social security number *

Address of current residence (number and street or rural route) City Work telephone number (include area code) State Residential telephone number (include area code) E-mail address ZIP code

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LICENSE SPECIFIC INFORMATION

If you are applying for either the Real Estate Salesperson or the Associate Broker license, and plan to work for an Independent Broker, please have the Independent Broker complete this section of the application. Note: Leave this section blank if you are applying to be a Real Estate Salesperson and wish to have your license placed in unassigned status or if you are applying to be an Independent Broker holding your own license.
Name of Independent Broker Address of current business (number and street or rural route) City Signature of Independent Broker State ZIP code Business telephone number (include area code) License number of Independent Broker

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Date signed (month, day, year)

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If you are applying for either the Real Estate Salesperson or the Associate Broker license, and plan to work for a Real Estate Professional Corporation (PC), Real Estate Corporation (CO), Limited Liability Company (LC) or Partnership (PA), please have the Principal Broker of that PC, CO, LC, or PA complete this section of the application. Note: Leave this section blank if you are applying to be a Real Estate Salesperson and wish to have your license placed in unassigned state or if you are applying to be an Independent broker holding your own license.
Name of Principal Broker Name of PC, CO, LC, or PA Address of current business (number and street or rural route) City Signature of Principal Broker State ZIP code Business telephone number (include area code) License number of Independent Broker License number of PC, CO, LC, or PA

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Date signed (month, day, year)

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NOTE: If you are applying for a Principal Broker license, you must file one of the following applications along with this application: 1) Application for Registration of Real Estate Professional Corporation 2) Application for Real Estate License as a Corporation 3) Application for Real Estate License as a Limited Liability Company 4) Application for Real Estate License as a Partnership PRE-LICENSING COURSE INFORMATION (to be completed by examination applicants only)
Have you completed a Commission-approved pre-licensing course?

Yes

No

Applying via Reciprocity

APPLICANTS MUST ATTACH AN ORIGINAL OR NOTARIZED COPY OF THEIR CERTIFICATE OF COURSE COMPLETION.
Name of Pre-Licensing Course Provider Location (city and state) Registration number of Indiana Pre-Licensing Course Provider Date of course completion (month, day, year) Number of course hours completed

LICENSING EXAMINATION INFORMATION (to be completed by examination applicants only)
Have you successfully completed both the National and State-Specific portions of the required licensing examination? Date examination(s) taken:

Yes

No

(Please provided information below)

APPLICANTS MUST ATTACH AN ORIGINAL OFFICIAL SCORE REPORT WITH THIS APPLICATION. OTHER STATE LICENSURE / CERTIFICATION / REGISTRATION / PERMIT APPLICANTS WHO ARE APPLYING FOR LICENSURE VIA RECIPROCITY MUST INCLUDE AN ORIGINAL OFFICIAL LICENSE VERIFICATION FROM THE STATE WHICH THEY ARE SEEKING TO RECIPROCATE FROM. VISIT THE COMMISSIONS WEBSITE FOR A LIST OF RECIPROCAL STATES.
Do you now hold, or have you ever held a license / certificate / registration / permit to practice or perform any regulated profession by a state licensing board?

Yes

No STATE

(If yes, list all states below, including Indiana in which you have held license / certification / registration / permit) LICENSE NUMBER DATE ISSUED (month, day, year) LICENSE STATUS

TYPE OF LICENSE / CERTIFICATION / REGISTRATION / PERMIT

If you answered Yes to any question #1 through #5, OR No to question #6 or #7 of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1) Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state, or by the Federal courts,or any agency of government, or are criminal charges now pending against you? (except for minor violations of traffic laws resulting in fines.) 2) Have you ever been denied a license, certification, registration or permit to practice real estate or any other profession in this or any other state? 3) Has any complaint been filed against you in the State of Indiana, or in any other state, regarding any professional license you currently hold or have previously held or have you practiced real estate or appraising as defined by IC 24-34.1 without a license? 4) Has disciplinary action ever been taken regading any professional license, certification, registration, or permit that you currently hold or have previously held? 5) Were you, at any time during your real estate course, recruited for employment or association with any real estate broker or company? 6) Were you informed, in writing, of the non-recruitment requirements contained in the Commissions administrative rules? 7) Do you agree to promptly return your license certificate and pocketcard if and when required by the Commission and to conform to all relevant statutes and to the administrative rules promulgated by the Commission? APPLICANT AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency, or the Indiana Real Estate Commission, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Commission, or any of their authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organization and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency, or the Indiana Real Estate Commission, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information, which is material to my application, and I hereby specifically release the Agency, and the Commission from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

NOTARY CERTIFICATE STATE OF ___________________________________ COUNTY OF _________________________________

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SS:

I, ______________________________________________________________________, being duly sworn on oath say that I am the above named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of notary public

Printed or typed name of applicant

Printed or typed name of notary public

Date subscribed and sworn to (Notary Public) (month, day, year)

County of residence

Date commission expires (month, day, year)