Free 43363.pdf - Indiana

APPLICATION FOR PERMIT FOR NONRESIDENT BROKER TO ACT AS AN INDIANA PRINCIPAL BROKER
State Form 43363 (R2/12-95)

OFFICE USE ONLY
Permit Number Date Issued

INSTRUCTIONS: Application must be accompanied by a certification of licensure from the real estate licensing authority state of residence that the applicant is currently licensed as a real estate broker in that state and that applicant's license has not been revoked or suspended, has not been in a probationary status for disciplinary reasons and has not been the subject of a reprimand in the residence state.

Indiana Professional Licensing Agency Indiana Government Center South 302 W. Washington St., Rm. E034 Indianapolis, IN 46204

Pursuant to IC 25-34. 1-4-3, designated principal broker of a partnership or corporation shall be a resident of Indiana. APPLICANT INFORMATION
Name of Applicant Resident Telephone Number Indiana Broker License Number

(
Address (Number and Street, City, State, ZIP code)

)
Broker License Number of State of Residence

Name of Business Which Applicant Will Conduct Business in Indiana Under the Nonresident Permit Business Telephone Number

Location of Proposed Location of Branch Office (s) in Indiana (If applicable)

(
Name of Bank in Indiana Where Indiana Trust Account Under the Permit is to be Maintained

)

Account Number

Indiana Bank Address (Number and Street, City, ZIP code) Have you ever been convicted of an act that would constitute a ground for disciplinary sanction under IC 25-34.1-6-1.1 or a crime that has a direct bearing on your ability to practice competently?

Yes

No

I, the undersigned applicant verify that all of the foregoing is true and that my real estate license in the state of is in good standing and has never been suspended or revoked or has not been the subject of a reprimand or been in a probationary status for disciplinary reasons.
Signature of Applicant Date

NOTARY CERTIFICATE

STATE OF COUNTY OF I,

}

SS:

, first 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 Commission Expires

Date Subscribed and Sworn To (Notary Public)

County of Residence