Application For Licensure By Reciprocity Form - Idaho Bureau Of Occupational Licenses

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STATE OF IDAHO
IDAHO REAL ESTATE APPRAISER BOARD
Bureau of Occupational Licenses
1109 Main Street, Suite 220
Boise, Idaho 83702-5642
APPLICATION FOR LICENSURE BY RECIPROCITY
(see instructions)
I hereby submit my qualifications and make application for a:
[ ] Licensed Residential
[ ] Certified Residential
[ ] Certified General
Appraiser license in the State of Idaho under the provisions of § 54-4115, Idaho Code as amended and provide the
following:
1. Full Name (Mr., Mrs., or Ms.) ________________________________________________________________
2. Mailing Address___________________________________________________________________________
Street/PO Box
City
State
Zip
3. Date of Birth _____/_____/_____ Place of Birth__________________ Social Security No.____/___/_____
month
day
year
Attach a passport photograph of yourself taken within 6 months of the date of this application.
4. Daytime phone _(____)____________ Fax _(____)______________ E-mail ________________________
5. List your ORIGINAL state of licensure ___________________ and license # _______________________
(Certification of said licensure(s) must be received directly from the licensing authority before your application will be processed.)
6. Are you currently or have you ever been licensed in any other state(s)?
[ ]Yes
[ ]No
(If Yes, attach a list of those states with dates of licensure and a photocopy of each current license.)
CONSENT TO SERVICE OF PROCESS and AFFIDAVIT
Know all persons by these presents:
Pursuant to the requirements of Chapter 41, Title 54, of the Idaho Code, I hereby irrevocably consent,
stipulate and agree that suits, actions and administrative proceedings may be commenced against me in the courts
and agencies of this State, by the service of any process authorized by the laws of this State on the Chief of the
Bureau of Occupational Licenses, and that service of such process upon said Chief shall be taken and held in all
courts to be as valid and binding as if the service had been made upon me in the State of Idaho.
I hereby certify under penalty of perjury that the responses provided above and those attached to this
application are true and accurate to the best of my knowledge and belief and that I will furnish all additional
information or documentation as may be deemed necessary for the verification of the information provided.
I further certify that I have reviewed and will comply with the Idaho Laws and Rules governing Real Estate
Appraiser practice. I hereby authorize and direct any person, agency, firm, or other entity to release to, upon the
request of the Bureau of Occupational Licenses or it’s authorized representative, any information, report,
communication, record, statement, recommendation, or disclosure that may have bearing on my eligibility for or
maintenance of the license for which I am applying. I understand that by signing this form I am authorizing the
release of information about me that may otherwise be protected or confidential.
___________________________________________
Signature of Applicant
State of ______________, County of _________________, ss.
Subscribed and sworn before me this ______ day of _______________________, 20 _____.
___________________________________________
(seal)
Notary Public official signature
residing at___________________________________
my commission expires________________________
REA-RA1 – 03/00

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