Sd Eform - 2160 V1 - Application For Registration - Appraisal Management Company Page 4
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4SECTION H: DECLARATIONS (continued)
10. that Entity maintains with the department the name and address of a registered agent for service of process; and notify the
department, within five days, of any change to the information on file;
11. that Entity will disclose to its client(s) the actual fees paid to an appraiser for appraisal services, separate from any other
fees or charges for appraisal management services, and make the information available to the department upon request;
12. that Entity will disclose its certificate of registration number within its engagement document with each utilized appraiser;
13. that Entity will retain records pursuant to ARSD 20:77:06:01;
14. that I understand and agree that the Department of Labor and Regulation may request additional information or
documentation deemed necessary for the verification of the information disclosed in this application;
15. that my failure to make a full and accurate disclosure of any information called for herein may result in the denial of a
certificate of registration. Further, any certificate of registration obtained on the basis of this application may be revoked or
suspended for my failure to disclose full and accurate information herein;
16. that I affirm that I have read and agree to comply with all provisions of the South Dakota Appraisal Management Company
laws and rules;
17. that I hereby authorize any state or Federal agency to release to the South Dakota Department of Labor and Regulation any
and all information concerning complaints or charges brought before it, whether or not the matter resulted in action against the
Entity. This authorization specifically includes information that may otherwise be deemed privileged or confidential. I hereby
also waive any procedural due process protections that may otherwise entitle the Entity to a hearing before the release of this
information.
I, ____________________________________, being first duly sworn on oath, depose and say under penalty of perjury that the
foregoing statements are true and correct.
State of: ____________________________________________
County of: __________________________________________
___________________________________________
SIGNATURE OF DESIGNATED OFFICER
Subscribed and sworn before me this _____ day of _________________, 20____.
__________________________________________________
NOTARY PUBLIC
My Commission expires:_______________________ My Commission Number is:_____________________________
SECTION I: Attachments
This application must be accompanied by a remittance of $1,000.00.
Attach documents specified by Section D.
Controlling Person’s contact information must be attached for each individual listed in Section E (unless included in Section F).
PRINT FOR MAILING
CLEAR FORM
Page 4 of 4
AMC APPLICATION (08/11)
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