Transfer Reactivation Application Form. This is a Ohio form and can be use in Department Of Commerce Statewide.
Tags: Transfer Reactivation Application, COM 3576, Ohio Statewide, Department Of Commerce
Ohio Department of Commerce Division of Real Estate & Professional Licensing 77 S. High Street • 20th Floor Columbus, OH 43215-6133 (614) 466-4100 • FAX (614) 644-0584 www.com.ohio.gov Ted Strickland Governor Kimberly A. Zurz Director BROKER TRANSFER / REACTIVATION APPLICATION This form is interactive. You may, before printing, type your responses directly onto the form. Incomplete applications and those that are filled out incorrectly will be returned for correction. 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. Individual fees are listed below or in the reactivation fee schedule on page 2. FOR DIVISION USE ONLY FEE AMOUNT BROKER NUMBER FILE NUMBER ISSUE DATE CE DUE DATE APPLICANT INFORMATION FILE NUMBER HOME ADDRESS LAST NAME FIRST NAME MIDDLE INITIAL OR NAME SUFFIX Check if new. CITY STATE ZIP CODE COUNTY HOME PHONE ( ) E-MAIL ADDRESS BROKER INFORMATION FILE NUMBER MAIN BUSINESS ADDRESS CITY OFFICIAL CORPORATION, L.L.C., PARTNERSHIP, OR ASSOCIATION NAME DOING BUSINESS AS (D.B.A.) NAME STATE ZIP CODE BUSINESS PHONE ( ) REASON FOR COMPLETING THIS FORM (Check all that apply. Remit one application fee per form even if you check multiple boxes.) If return of a license is required, include the ORIGINAL license and company addendum. If original license is lost, please remit a Change Application – Individual with a $20 fee. TRANSFER TO A NEW BROKERAGE – $25 fee (include the original license and broker addendum from the broker’s current company and from the broker’s prospective company) TRANSFER FROM A CORPORATE BROKERAGE TO AN INDIVIDUAL (SOLE) BROKER – $25 fee (include a letter from the bank stating that the broker has opened a non-interest bearing trust or special account, including approved account name/approved D.B.A. name and account number; and the original license and broker addendum from the broker’s current company) REACTIVATE LICENSE FROM INACTIVE STATUS – $25 fee (include the original license and broker addendum from the broker’s prospective company) REACTIVATE LICENSE TO ACTIVE STATUS FROM RENEWAL SUSPENSION – see fee schedule on page 2 (include Broker Information and return the original license and broker addendum) REACTIVATE LICENSE TO INACTIVE STATUS FROM RENEWAL SUSPENSION – see fee schedule on page 2 (skip Broker Information and return the original license and broker addendum if license was active prior to suspension) REACTIVATE LICENSE TO ACTIVE STATUS FROM 10-HOUR POST LICENSE EDUCATION SUSPENSION – $25 fee (include Broker Information and return original license and broker addendum) REACTIVATE LICENSE TO INACTIVE STATUS FROM 10-HOUR POST LICENSE EDUCATION SUSPENSION – $25 fee (skip Broker Information) PLACE BROKER LICENSE IN INACTIVE STATUS – no fee (skip Broker Information and return original license and broker addendum) * Inactive licensees are required to submit renewal and continuing education by due date every three years.* PLACE SALESPERSON LICENSE IN INACTIVE STATUS AND REQUEST BROKER LICENSE – $25 fee (include original salesperson license) PLACE BROKER LICENSE IN INACTIVE STATUS AND REQUEST SALESPERSON LICENSE – $25 fee (include the original license and broker addendum) REACTIVATE LICENSE TO ACTIVE STATUS FROM ENFORCEMENT ACTION – $25 fee REACTIVATE LICENSE TO INACTIVE STATUS FROM ENFORCEMENT ACTION – $25 fee 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 or rejection or withdrawal of approval of this application. COM 3576 (Rev. 10/2008) “An Equal Opportunity Employer and Service Provider” Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Licensees reactivating from Renewal/Continuing Education Suspension owe the following fees: Renewal Fee Late Renewal Penalty Reactivation Fee Total $147.00 $73.50 $25.00 $245.50 Licensees who have paid the renewal fee should remit the Late Renewal Penalty and the Reactivation Fee. 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 your most recent filing of an application for Ohio real estate licensure, renewal or transfer/reactivation application, 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? * If license is currently suspended, check “yes.” SUSPENSION REASON: 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? YES NO been the subject of any unsatisfied judgments? YES NO been convicted of, plead guilty to or been granted intervention in lieu of conviction for any unlawful conduct excluding minor traffic violations? LIST:_________________________________________________________ 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 ONLY IF THE APPLICANT IS REQUESTING A SALESPERSON LICENSE (PLACING BROKER LICENSE IN INACTIVE STATUS) 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 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com