Corporation Background Statement Form. This is a California form and can be use in Department Of Real Estate Statewide.
Tags: Corporation Background Statement, RE 212, California Statewide, Department Of Real Estate
STATE OF CALIFORNIA DEPARTMENT OF REAL ESTATE Serving Californians Since 1917 CORPORATION BACKGROUND STATEMENT RE 212 (Rev. ) Read reverse side before completing. BACKGROUND INFORMATION 1. NAME OF DIRECTOR, OFFICER, STOCKHOLDER, ETC. (SEE INFORMATION ABOVE.) 2. CORPORATION NAME 3. DRE CORP. ID# (if issued) 4. POSITION/TITLE WITH CORPORATE LICENSE APPLICANT 5. BIRTH DATE 6. WITHIN THE LAST TEN YEARS, HAVE YOU RECEIVED AN ORDER OR JUDGMENT ISSUED BY A COURT OR GOVERNMENTAL AGENCY TEMPORARILY OR PERMANENTLY RESTRAINING OR ENJOINING ANY BUSINESS CONDUCT, PRACTICE, OR EMPLOYMENT? YES DATE OF ACTION 7. NO IF YES, COMPLETE THE FOLLOWING. AGENCY/COURT CASE # ADDRESS EXPLANATION WITHIN THE LAST TEN YEARS, HAVE YOU HAD A BUSINESS/PROFESSIONAL LICENSE TO PRACTICE IN REAL ESTATE OR OTHER REGULATED PROFESSION, OCCUPATION, OR VOCATION DENIED, SUSPENDED, RESTRICTED, OR REVOKED IN CALIFORNIA OR ANY OTHER STATE? ATTACH ADDITIONAL SHEETS IF NECESSARY. YES NO TYPE OF LICENSE 8. IF YES, COMPLETE THE FOLLOWING. LICENSE EXPIRATION DATE LICENSE IDENTIFICATION # STATE (ISSUED BY) WITHIN THE LAST TEN YEARS, HAVE YOU CONDUCTED ACTIVITIES INVOLVING ACTS REQUIRING A REAL ESTATE LICENSE OF ANY STATE WITHOUT THE BENEFIT OF A VALID LICENSE OR PERMIT AUTHORIZING THAT CONDUCT, WHICH HAVE BEEN ENJOINED BY A COURT OF LAW OR ADMINISTRATIVE TRIBUNAL? YES NO IF YES, COMPLETE THE FOLLOWING. COURT OF CONVICTION CODE NUMBER VIOLATED 9. CASE # ARRESTING AGENCY CODE SECTION VIOLATED DATE OF CONVICTION DISPOSITION WITHIN THE LAST TEN YEARS, HAVE YOU BEEN CONVICTED OF ANY VIOLATION OF LAW? (YOU MAY OMIT MINOR TRAFFIC CITATIONS WHICH DO NOT CONSTITUTE A MISDEMEANOR OR FELONY.) ATTACH ADDITIONAL SHEETS IF NECESSARY. YES NO IF YES, COMPLETE THE FOLLOWING. "Convicted" as used in this question includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed whether the plea or verdict was set aside and the charges against you dismissed or expunged under Section 1203.4 of the California Penal Code or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under California Penal Code Section 1203.45 or Section 781 of the California Welfare and Institutions Code. COURT OF CONVICTION ARRESTING AGENCY DATE OF CONVICTION CODE NUMBER VIOLATED CODE SECTION VIOLATED DISPOSITION CERTIFICATION I declare under penalty of perjury that the answers and statements given in this Background Statement are true and correct except where stated upon information and belief. You should review your application to insure it has been properly completed. Failure to complete required portions of the application could result in either processing delays or denial of the license. 10. SIGNATURE OF DIRECTOR, CHIEF EXECUTIVE OFFICER, ETC. 11. DATE American LegalNet, Inc. www.FormsWorkFlow.com RE 212 — Reverse INSTRUCTIONS A separate RE 212 must be completed by each director, chief executive ofﬁcer, president, ﬁrst level vice presidents, secretary, chief ﬁnancial ofﬁcer, subordinate ofﬁcers with responsibility for forming policy of the corporation and all natural persons owning or controlling more than ten percent of its shares who have an afﬁrmative response to one or more of questions 6 through 9. Attach additional pages if more space is needed; each additional page must be appropriately numbered to correspond to the question being answered and signed by the applicant. Failure to provide complete answers to all of the following questions could result in either processing delays or denial of the license. Please type or print in ink. Proof of Legal Presence One individual per form. Reproduce as necessary. (Only legible photocopies are acceptable; however, signatures must be originals.) Effective August 1, 1998, all applicants for a real estate salesperson, broker, or ofﬁcer license, must submit proof that they have legal presence in the United States. A proof of legal presence document (i.e. birth certiﬁcate, resident alien card, etc.) must be submitted with a State Public Beneﬁts Statement (RE 205) before a license will be issued. Please refer to that form for further instructions. If you electronically re-create this form to facilitate completion on a computer, please be advised that the form should not be altered in any manner. To do so, could result in disciplinary action. Also, please make certain you do not delete any preprinted information and are using the latest version of the form. PRIVACY INFORMATION: Section 1798.17 of the Civil Code requires this notice be provided when collecting personal or conﬁdential information from individuals. Each individual has the right to review personal information maintained by this Agency, unless access is exempted by law. Department of Real Estate Managing Deputy Comm. IV 2201 Broadway Licensing, Exam., & Education Sacramento, CA 95818 Telephone: 877-373-4542 General powers of the Commissioner, Sections 10050, 10071, and 10075 of the Business and Professions Code authorizes the maintenance of this information. Business and Professions Code Section 30, Chapter 1361, Section 1, requires each real estate licensee to initially provide to the Department of Real Estate his or her social security number which will be furnished to the Franchise Tax Board. Providing your social security number on this application is optional, but can assist DRE in correcting any future social security number discrepancies. Your social security number shall not be deemed a public record and shall not be open to the public for inspection. The Franchise Tax Board will use your number to establish identiﬁcation exclusively for tax purposes. The Real Estate Law and the Regulations of the Commissioner require applicants to provide the Department with speciﬁc information. If all or any part of the required information is not provided, processing may be delayed. In addition, the Commissioner may suspend or revoke a license, or in the case of a license applicant, may deny the issuance for misstatements of facts (including a failure to disclose a material fact) in an application for a license. The information requested in this form is primarily used to furnish license status information to the Department’s Regulatory Section, and to answer inquiries and give information to the public on license status, mailing and business addresses and actions taken to deny, revoke, restrict or suspend licenses for cause. This information may be transferred to real estate licensing agencies in other states, law enforcement agencies (City Police, Sheriff’s Departments, District Attorneys, Attorney General, F.B.I.), and any other regulatory agencies (i.e., Department of Corporations, Department of Insurance, Department of Consumer Affairs, California Bar Association). American LegalNet, Inc. www.FormsWorkFlow.com