Qualified Association Application Form Page 2
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1
203/2017
Phone Number 717-783-3658
STATE REAL ESTATE COMMISSION
Fax Number: 717-787-0250
PO Box 2649
Harrisburg PA 17105-2649
QUALIFIED ASSOCIATION APPLICATION
1. Name of Qualified Association:
2. Address of Qualified Association:
(Street Address)
(City)
(State)
(Zip)
3. In which jurisdiction is the entity registered?
4. Date the entity was registered: __ __ / __ __ / __ __ __ __
5. List the name and license number of all owners of the Qualified Association:
Name:
License Number:
Name:
License Number:
Name:
License Number:
Name:
License Number:
6. Name and License Number of the Broker that all Qualified Association Owners are affiliated with:
(Name as it appears on license)
(License Number)
APPLICANT’S CERTIFICATION - MUST BE SIGNED BY ALL OWNERS/OFFICERS/PARTNERS
By submitting this information, I/we verify that this application is in the original format as supplied by the
Department of State and has not been altered or otherwise modified in any way. I/we am aware of the
criminal penalties for tampering with public records or information under 18 Pa.C.S. § 4911. I/we verify
that the statements in this application are true and correct to the best of my knowledge, information and
belief.
I/we understand that false statements are made subject to the penalties of 18 Pa.C.S. § 4904
(relating to unsworn falsification to authorities) and may result in the suspension, revocation or denial of
my license, certificate, permit or registration.
(Owner/Officer/Partner Signature)
(Date)
(Owner/Officer/Partner Signature)
(Date)
(Owner/Officer/Partner Signature)
(Date)
(Owner/Officer/Partner Signature)
(Date)
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