Please visit our website at www.com.ohio.gov/real 614 | 466-4100 Fax 614 | 644-0584 TTY/TDD: 800 | 750-0750 FOR DIVISION USE ONLY LICENSE FEE ($150.00) FILE/LICENSE NUMBER EXAMINATION FEE ($75.00) DEALER NUMBER INSTRUCTIONS: FORM 27CI INDIVIDUAL CORPORATE DEALER APPLICATION FOREIGN REAL ESTATE (Pursuant to Chapter 4735.27 of the Ohio Revised Code) 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. NAME OF APPLICANT RESIDENCE ADDRESS (STREET, CITY, COUNTY, STATE, ZIP CODE) RESIDENCE PHONE SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY) EMAIL ADDRESS 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 issued to the applicant named herein. SIGNATURE OF DEALER DATE The applicant states that the information given in this application is accurate 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 APPLICANT DATE COM 3570 (REV. 09/2012) Equal Opportunity Employer and Service Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com