Please visit our website at www.com.ohio.gov/real 614|466 - 4100 Fax: 614|644 - 0584 TTY/TDD: 800|750 - 0750 Anne M. Petit , Superintendent REAL ESTATE RETAKE APPLICATION BROKER FEE: $100 SALESPERSON FEE: $60 A check or m oney order for any fees, m ade payable to the Divis i on of Real Estate & Professional Licensing, m u st acco m p any this app li ca ti on. Cash will not be accepted. The na m e and date of birth on t h is application m u st m atch t h e na m e and date of birth on t h govern m ent - issued photo ID for identity verification at the exa m ination site. FOR DIVISION USE ONLY EXAMS BROKER STATE AND NATIONAL SALESPERSON STATE AND NATIONAL BROKER NATIONAL ONLY SALESPERSON NATIONAL ONLY BROKER STATE ONLY SALESPERSON STATE ONLY APPLICANT INFORMATION CANDIDATE ID NUMBER FIRST NAME MIDDLE INITIAL OR NAME LAST NAME SUFFIX HOME ADDRESS PHONE NUMBER SSN CITY STATE ZIP CODE COUNTY DATE OF BIRTH EMAIL ADDRESS SPONSORING BROKER INFORMATION CHECK IF SPONSORING BROKER INFORMATION HAS CHANGED SINCE LAST SUBMISSION COMPANY FILE NUMBER 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 . QUESTIONS CONCERNING PROFESSIONAL LICENSES APPLY TO ALL PROFESSIONAL LICENSES REGARDLESS OF PROFESSION. SINCE the last filing of your application for Ohio real estate licensure, have you: YES NO B een 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 , including the Ohio Division of Real Estate ? YES NO B een refused or denied any professional license or registration by any public entity , including the Ohio Division of Real Estate ? YES NO H ad any professional license revoked, suspended or limited in any way for any reason? YES NO B een 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 , including the Ohio Division of Real Estate ? YES NO B een the subject of any unsatisfied judgm ents? YES NO B een 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 state m ents on this application and all of the attached ma terials are co m p lete and accurate. I unders t and that any false state m ent on this form m ay subject m e to cri m inal pro sec u ti o n a n d t h e l o ss o f m y O h io real estate lice n se. SIGNATURE OF APPLICANT DATE THE SPONSORING BROKER MUST COMPLETE THE FOLLOWING CERTIFICATION I hereby cer ti fy t h a t , from t h e i nves ti g a ti ons m ade by m e, I f i nd t h e above li s t ed app li cant for a real es t a t e li cense i s honest, t ru t hful and of good reputation. I understand t h at any false state m ent on t h is form t h at is known to m e at t h e ti m e of m y signing m ay s ubject m e to cri m i n al p r o sec u ti o n a n d t h e l o ss o f m y O h io real estate lice n se. NAME OF BROKER (please type or print) FILE NUMBER SIGNATURE OF BROKER DATE NOTIC E : Thi s applicatio n an d th e informatio n conta i ne d therein , excep t fo r th e socia l secur i t y number , i s publi c recor d pursuan t t o Ohi o Revise d Cod e 149.43. NOTIC E : Refusa l o f chec k pa y men t b y th e dra w s ban k ma y resul t i n a one - hundred - dolla r fe e t o th e superintenden t and/o r th e reject i o n o r w i thdra w a l of approva l o f thi s application. CO M 366 4 (Rev . 8/2014 ) Equal Opportunity Employer and Service Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com