Individual Corporate Dealer Application Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Individual Corporate Dealer Application, COM 3570, Ohio Statewide, Department Of Commerce
Ohio Department of Commerce Division of Real Estate & Professional Licensing Governor th 77 South High Street • 20 Floor Columbus, OH 43215-6133 (614) 466-4100 Fax:(614) 644-0584 www.com.ohio.gov Director FOR DIVISION USE ONLY LICENSE FEE ($150.00) FILE/LICENSE NUMBER EXAMINATION FEE ($75.00) DEALER NUMBER FORM 27CI INDIVIDUAL CORPORATE DEALER APPLICATION – FOREIGN REAL ESTATE (Pursuant to Chapter 4735.27 of the Ohio Revised Code) INSTRUCTIONS: • This application is for an individual dealer associated with the corporate dealer applicant. • Incomplete application forms will delay the application process. • Application forms must be typed in black ink only. • The license fee is $150.00 and is nonrefundable. • The examination fee is $75.00 and is nonrefundable once the Division has scheduled the applicant for the examination. • A check or money order payable to the Division of Real Estate must accompany this application. Do not send cash. • An Ohio Department of Public Safety State Issued License form must accompany this application. NAME OF APPLICANT RESIDENCE ADDRESS (STREET, CITY, COUNTY, STATE, ZIP CODE) RESIDENCE PHONE ( SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY) ) DEALER WITH WHOM THE APPLICANT IS EMPLOYED DEALER BUSINESS PHONE ( ) DEALER BUSINESS ADDRESS (STREET, CITY, COUNTY, STATE, ZIP CODE) Have you ever been licensed in Ohio as a foreign real estate dealer or salesperson? NO YES – Please indicate the period licensed and type of transactions ______________________________________________________________ Have you ever been licensed by the Ohio Division of Real Estate as a broker or salesperson? NO YES – Please indicate the period licensed and type and number of transactions ____________________________________________________ Have you ever been licensed, other than in Ohio, by a public officer or body, corresponding to the Ohio Division of Real Estate, that regulates real estate licenses? NO YES – Please indicate the licensing body, date licensed and type of license _______________________________________________________ Have you ever been convicted of any unlawful conduct (excluding minor traffic violations)? NO YES – Please attach an explanation Have you ever had any disciplinary action taken against you by any state or federal agency? NO YES – Please attach an explanation Have you ever been refused a license or permit by any licensing authority of any state? NO YES – Please attach an explanation Attach the following information: • A list of all education from high school to present, including institution, degree and date earned. • The names and addresses of employers of the applicant for the preceding ten years. • The names, addresses and occupations of five references, other than family members and former employers. THE DEALER MUST COMPLETE THE FOLLOWING CERTIFICATION THE APPLICANT MUST COMPLETE THE FOLLOWING CERTIFICATION The undersigned licensed dealer hereby requests that a sales license be The applicant states that the information given in this application is accurate issued to the applicant named herein. and complete and that such information is furnished for the purpose of procuring an individual corporate foreign real estate dealers license pursuant to Section 4735.27 of the Ohio Revised Code. _________________________________ _________________ _________________________________ ________________ SIGNATURE OF DEALER DATE SIGNATURE OF APPLICANT DATE FINANCIAL INSTITUTIONS REAL ESTATE & PROFESSIONAL LICENSING COM 3570 (REV. 04/2006) INDUSTRIAL COMPLIANCE SECURITIES LABOR & WORKER SAFETY LIQUOR CONTROL STATE FIRE MARSHAL UNCLAIMED FUNDS “An Equal Opportunity Employer and Service Provider” Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com