Free 50670.PDF - Indiana

REQUEST FOR ISSUANCE / TRANSFER OF INDIANA TRAINEE APPRAISER LICENSE
State Form 50670 (R / 1-03)

Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, IN 46204-2700 Telephone: 317-232-2980 FAX: 317-232-2312

IMPORTANT! Applicant - you must return this completed form to the above address in order for a license to be issued. PART A (to be filled out by trainee applicant)
Date (month, day, year) Telephone number Trainee license number

Name of applicant

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

PART B (to be filled out by employer) If no employer, please check here for an inactive license.
Instructions: Prior to completing this section, please read IC 25-34.1 and 876 IAC (Indiana statute and rules) regarding prohibitions, supervision, and required use of licensed trainee appraisers.
Name of Supervising Appraiser

Business address (number and street, city, state, ZIP code)

Indiana appraiser license number

NOTARY CERTIFICATE

STATE OF }SS COUNTY OF SEAL

I, , having been duly sworn on oath, say that I am the above-named supervising appraiser, and hereby certify that the individual named as the Applicant in Section A of this form is associated with myself as an Indiana licensed trainee appraiser. I further agree to return this licensed trainee appraiser's license to the Indiana Professional Licensing Agency within five (5) working days of the termination of the aforementioned association.
Signature of supervising appraiser Signature of Notary Public

Printed or typed name of supervising appraiser

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

County of residence

Date commission expires