Retake Application Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Retake Application, COM 3664, Ohio Statewide, Department Of Commerce
Please visit our website at www.com.ohio.gov/real 614 | 466-4100 Fax 614 | 644-0584 TTY/TDD: 800 | 750-0750 RETAKE APPLICATION REAL ESTATE BROKER AND SALESPERSON A check or money order for any fees, made payable to the Division of Real Estate & Professional Licensing, must accompany this application. Cash will not be accepted. The name and date of birth on this application must match the name and date of birth on the applicant’s government-issued photo ID for identity verification at the examination site. FOR DIVISION USE ONLY FILE NUMBER EXAMS BROKER – STATE AND NATIONAL $100.00 SALESPERSON – STATE AND NATIONAL $60.00 BROKER – NATIONAL ONLY $100.00 SALESPERSON – NATIONAL ONLY $60.00 BROKER – STATE ONLY $100.00 SALESPERSON – STATE ONLY $60.00 APPLICANT INFORMATION CANDIDATE ID NUMBER FIRST NAME MIDDLE NAME HOME ADDRESS LAST NAME HOME PHONE ( CITY STATE ZIP CODE SUFFIX (JR., SR.) SOCIAL SECURITY NUMBER ) COUNTY DATE OF BIRTH (mm/dd/yyyy) E-MAIL ADDRESS SPONSORING BROKER INFORMATION COMPANY FILE NUMBER CHECK IF SPONSORING BROKER INFORMATION HAS CHANGED SINCE LAST SUBMISSION BROKER/COMPANY NAME BUSINESS PHONE ( MAIN BUSINESS ADDRESS (NOT A BRANCH OFFICE ADDRESS) CITY ) STATE ZIP CODE ETHICAL CONDUCT AND LEGAL HISTORY PLEASE ATTACH A COMPLETE EXPLANATION FOR ANY QUESTIONS ANSWERED “YES.” QUESTIONS CONCERNING PROFESSIONAL LICENSES APPLY TO ALL PROFESSIONAL LICENSES REGARDLESS OF PROFESSION. SINCE the filing of your application for Ohio real estate licensure, have you: been disciplined in any manner by any public entity or professional or trade association for any violation of any professional licensing law, regulation or ethical rule? YES NO YES NO been refused or denied any professional license or registration by any public entity? YES NO had any professional license revoked, suspended or limited in any way for any reason? YES NO YES NO been the subject of any unsatisfied judgments? YES NO been notified by any public entity or professional or trade association that you were under investigation for any violation of any professional licensing law, regulation or ethical rule? been convicted of, plead guilty to or been granted intervention in lieu of conviction for any unlawful conduct excluding minor traffic violations? THE APPLICANT MUST COMPLETE THE FOLLOWING CERTIFICATION I certify that all of the statements on this application and all of the attached materials are complete and accurate. I understand that any false statement on this form may subject me to criminal prosecution and the loss of my Ohio real estate license. ___________________________________ _______________ SIGNATURE OF APPLICANT DATE THE SPONSORING BROKER MUST COMPLETE THE FOLLOWING CERTIFICATION I hereby certify that, from the investigations made by me, I find the above listed applicant for a real estate license is honest, truthful and of good reputation. I understand that any false statement on this form that is known to me at the time of my signing may subject me to criminal prosecution and the loss of my Ohio real estate license. ___________________________________ _______________ __________________________________ _______________ NAME OF BROKER (please type or print) SIGNATURE OF BROKER FILE NUMBER DATE NOTICE: This application and the information contained therein, except for the social security number, is public record pursuant to Ohio Revised Code 149.43. NOTICE: Refusal of check payment by the drawer’s bank may result in a one-hundred-dollar fee to the superintendent and/or the rejection or withdrawal of approval of this application. COM 3664 (Rev. 02/2010) “An Equal Opportunity Employer and Service Provider” Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com