S
C
tate of
alifornia
B
r
e
ureau of
eal
State
C
B
S
orporation
aCkground
tatement
Read reverse side before completing.
RE 212 (Rev. 1/16)
Background InformatIon
1.
Name of Director, officer, StockholDer, etc. (See reverSe.)
2.
corporatioN Name
3.
calbre corp. liceNSe iD# (if issued)
4.
poSitioN/title with corporate liceNSe applicaNt
5.
birth Date
6.
withiN the laSt teN yearS, have you receiveD aN orDer or juDgmeNt iSSueD by a court or goverNmeNtal ageNcy temporarily or permaNeNtly reStraiNiNg
or eNjoiNiNg aNy buSiNeSS coNDuct, practice, or employmeNt?
yes
No
if yeS, complete the followiNg.
date of action
agency/court
case #
address
explanation
7.
withiN the laSt teN yearS, have you haD a buSiNeSS/profeSSioNal liceNSe to practice iN real eState or other regulateD profeSSioN, occupatioN, or vocatioN
DeNieD, SuSpeNDeD, reStricteD, or revokeD iN califorNia or aNy other State? attach additional sheets if necessary.
yes
No
if yeS, complete the followiNg.
type of license
license expiration date
license identification #
state (issued by)
8.
withiN the laSt teN yearS, have you coNDucteD activitieS iNvolviNg actS requiriNg a real eState liceNSe of aNy State without the beNefit of a valiD liceNSe
or permit authoriziNg that coNDuct, which have beeN eNjoiNeD by a court of law or aDmiNiStrative tribuNal?
yes
No
if yeS, complete the followiNg.
court of conviction
case #
arresting agency
date of conviction
code number violated
code section violated
disposition
"convicted" as used in question 9 below includes:
• All state, commonwealth, possession, or federal misdemeanor and felony convictions, and all military and foreign convictions.
• A verdict of guilty by judge or jury, a plea of guilty, a plea of nolo contendere (or "no contest"), or a forfeiture of bail in the courts.
• convictions expunged under Penal code sections 1203.4, 1203.4a and 1203.41 or equivalent non-california statute must
still be disclosed. Proof that a conviction has been expunged under Penal code sections 1203.4, 1203.4a and 1203.41
must be submitted with the application.
• Convictions must be disclosed no matter how long ago they occurred and whether the convicted person was a minor (under 18
years of age, if tried as an adult).
Exceptions to "convicted": do not dIScLoSE
• Any Juvenile Court adjudication.
• Any conviction sealed under Penal Code section 1203.45 or Welfare and Institutions Code section 781.
• Any conviction under Health and Safety Code section 11357(b), (c), (d), or (e), or Health and Safety Code section 11360(b)
aftEr at least two years have passed since the date of the conviction.
9.
withiN the laSt teN yearS, have you beeN coNvicteD of aNy violatioN of law? (you may omit minor traffic citations which do not constitute a misdemeanor
or felony.) attach aDDitioNal SheetS if NeceSSary.
yes
No
if yeS, complete the followiNg.
court of coNvictioN
arreStiNg ageNcy
Date of coNvictioN
coDe Number violateD
coDe SectioN violateD
DiSpoSitioN
cErtIfIcatIon
i declare under penalty of perjury that the answers and statements given in this background statement are true and correct except where
stated upon information and belief.
You should review your application to insure it has been properly completed. failure to complete required portions of the application
could result in either processing delays or denial of the license.
10. SIgnAture of DIreCtor, CHIef exeCutIve offICer, etC.
11. DAte