Free Print File - Michigan

This document can be completed on-line, printed and mailed to Testing & Education Services. This BCS/LRE-005 (01/09) form cannot be submitted electronically. If you need Side 1 of 2 to clear the form for any reason, click the clear Michigan Department of Energy, Labor & Economic Growth button. Bureau of Commercial Services
Testing, Education & Program Services P.O. Box 30018, Lansing, MI 48909 517-241-9295 Fax: 517-241-7539 www.michigan.gov/bcstesting

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VERIFICATION OF ATTENDANCE AT REAL ESTATE SALESPERSON PRELICENSURE EDUCATION COURSE

AUTHORITY: P.A. 299 of 1980, as amended COMPLETION: Mandatory PENALTY: Failure to complete may result in denial of students' application for licensure Information provided on this form may be released to the public in accordance with the Freedom of Information Act, 1976 PA 442, as amended.

Rule 604(8) Within 5 business days of the conclusion of the last course, schools and sponsors shall submit, in a format requried by the department, the names of studens who have successfully completed an approved course. School Code Title of Course Class Number Name of School Location of Class Or, Check if Online

In accordance with P.A. 299 of 1980, as amended, §2504, the following individuals have satisfactorily completed a real estate prelicensure course consisting of hours completed on the following date: Printed Name of Course Instructor/Coordinator Signature of Course Instructor/Coordinator

TYPE INFORMATION BELOW IN ALPHABETICAL ORDER LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 *Needs to be completed if an approved online course. TURN OVER AND CONTINUE. SUBMIT ADDITIONAL SHEETS AS NECESSARY DATE OF BIRTH *Number of Minutes NAME (Last, First and Middle Initial)

BCS/LRE-005 (01/09) Side 2 of 2

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*Needs to be completed if an approved online course. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
DELEG is an equal opportuinty employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilties.

DATE OF BIRTH

NAME (Last, First and Middle Initial)