Free 48359.PDF - Indiana

APPLICATION FOR WAIVER OF CONTINUING EDUCATION
State Form 48359 (4-97)

STATE OF INDIANA INDIANA REAL ESTATE COMMISSION INDIANA PROFESSIONAL LICENSING AGENCY 302 West Washington Street, Room E034 Indianapolis, IN 46204

Requesting waiver on the basis of (check one): Service in the armed forces of the United States for one (1) year or more of the two (2) year licensure period. An incapacitating illness which has prevented either part-time or full-time employment for at least twelve (12) months of the two (2) year licensure period. ** PLEASE PROVIDE EVIDENCE OF SERVICE IN THE ARMED FORCES OR A DOCTOR'S STATEMENT VERIFYING THE INCAPACITATING ILLNESS PURSUANT TO 876 IAC 4-2-11.
Name of applicant License number

Address (number and street, city, state, ZIP code)

C/S/Z

Signature of applicant

Date (month, day, year)

Reason for request:

FOR OFFICE USE ONLY Approved
Comments:

Tabled

Denied

Signature

Date (month, day, year)