Change Of Employer Application - Standard Or Reciprocal Licensees (Page 4 of 4) in pdf

56-SPOA 2102 (6/13)

17. Are you the subject of a pending criminal or disciplinary investigation?

Yes – Where:

When:

18. Have you ever been convicted, found guilty or pleaded nolo contendere as to any felony or

misdemeanor, or do you have any criminal charges pending and unresolved in any state or

jurisdiction?

Yes (If yes, include the information requested in section 9 in the instructions.)

Please note that you are not required to disclose any criminal matter that has been expunged

by order of a court.

19. Have you withdrawn an application for a license, certificate, or registration, had an application denied

or refused, or, for disciplinary reasons, agreed not to reapply for a license, certificate, or registration

in any profession in any state or jurisdiction?

Yes – Where:

When:

SOCIAL SECURITY CERTIFICATION

Note that disclosing your social security number on this application is mandatory in order for the State

Real Estate Commission to comply with the requirements of the federal Social Security Act pertaining to

child support enforcement, as implemented in the Commonwealth of Pennsylvania at 23 Pa. C.S.

§4304.1(a). In order to enforce domestic child support orders, the Commonwealth’s licensing boards

must provide to the Department of Public Welfare information prescribed by DPW about the licensee,

including the social security number.

EMPLOYER’S CERTIFICATION

I do hereby request that a license be granted to ___________________________________________ to

provide real estate services at this office. I certify that the above applicant bears a good reputation for

honesty, trustworthiness, integrity and competence and I will actively train and supervise the applicant as

required by Real Estate Licensing and Registration Act and the Commission’s Regulations.

(Employer’s Signature)

(License Number)

(Date)

APPLICANT’S CERTIFICATION

To the best of my knowledge, all information supplied in this application is true and correct.

To the best of my knowledge, I have accurately answered whether I am the subject of discipline or

under current investigation or proceedings alleging misconduct under a licensing or criminal law in

this Commonwealth or another state.

I have read, understand and agree to comply with the Real Estate Licensing and Registration Act

and the Commission’s Regulations.

I agree to permit the disclosure of my licensure record, including any disciplinary history from

every state in which I am or have been licensed or will be licensed in the future.

I consent to service of process as described in 49 Pa. Code §35.221(3) (relating to general

requirements).

I understand that any false statement made by me is subject to the penalties of 18 Pa. C.S. §4904

(relating to unsworn falsification to authorities) and may result in a disciplinary sanction against

my license.

(Applicant’s Signature)

(Date)

Change Of Employer Application - Standard Or Reciprocal Licensees Page 4

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