Pl 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 BROKER TRANSFER / REACTIVATION APPLICAT IO N 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. FOR DIVISION USE ONLY 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. APPLICANT INFORMATION FILE NUMBER FIRST NAME MIDDLE NAME OR INITIAL LAST NAME SUFFIX HOME ADDRESS Check if new CITY STATE COUNTY ZIP CODE PHONE NUMBER EMAIL ADDRESS BROKERAGE INFORMATION COMPANY FILE NUMBER COMPANY NAME MAIN BUSINESS ADDRESS DOING BUSINESS AS (D.B.A.) NAME CITY STATE COUNTY ZIP CODE PHONE NUMBER 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. If original license is lost, please remit a Change Application Individual with a $25 fee. TRANSFER TO A NEW BROKERAGE $25 fee prospective company) REACTIVATE LICENSE FROM INACTIVE STATUS $25 fee 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 SUSPENSIO N $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 BROKER LICENSE IN INACTIVE STATUS AND REQUEST SALESPERSON LICENSE $25 fee (include the original license and broker addendum) PLACE SALESPERSON LICENSE IN INACTIVE STATUS AND REQUEST BROKER LICENSE -- $25 fee (return original salesperson license, company license and broker addendum) REACTIVATE LICENSE TO ACTIVE STATUS FROM FAILURE TO COMPLY WITH IMPOSED DISCIPLINE FROM ENFORCEMENT ACTION -- $25 fee REACTIVATE LICENSE TO INACTIVE STATUS FROM FAILURE TO COMPLY WITH IMPOSED DISCIPLINE FROM ENFORCEMENT ACTION -- $25 fee **PLEASE COMPLETE PAGES 1 AND 2 OF THIS FORM COM 3576 (Rev. 6/2017) Page 1 of 2 REPL - 17 - 0012 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 Licensees who have paid the $1 80 renewal fee should remit the Late Renewal Penalty and the Reactivation Fee. $180.00 $90.00 $25.00 $295.00 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 YOUR MOST RECENT FILING of an application for Ohio real estate licensure, renewal or transfer/reactivation application, have you: YES NO 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, including the Ohio Division of Real Estate? YES NO Been refused or denied any pro fessional license or registration by any public entity, including the Ohio Division of Real Estate? YES NO Had any professional license revoked, suspended or limited in any way for any reason? 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, including the Ohio Division of Real Estate? YES NO B een 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 PRINCIPAL BROKER MUST DESIGNATE LICENSE LEVEL AND COMPLETE THE FOLLOWING CERTIFICATION PRINCIPAL BROKER MANAGEMENT LEVEL BROKER ASSOCIATE BROKER MANAGEMENT LEVEL SALESPERSON SALESPERSON 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 si gning may subject me to criminal prosecution and the loss of my Ohio real estate license. NAME OF PRINCIPAL BROKER(please type or print) FILE NUMBER SIGNATURE OF PRINCIPAL BROKER DATE NOTICE: This application and the information contained therein, except for the social security number, is public record pursuant to O hio Revised Code 149.43. NOTICE: - hundred - dollar fee to the supe rintendent or rejection or withdrawal of approval of this application. Page 2 of 2 REPL-17-0012 American LegalNet, Inc. www.FormsWorkFlow.com