Criminal Conviction/disciplinary Action/judgment Reporting Form - North Carolina Appraisal Board

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NORTH CAROLINA APPRAISAL BOARD

5830 Six Forks Road, Raleigh, NC 27609

Phone (919)870-4854 Fax (919)870-4859

CRIMINAL CONVICTION/DISCIPLINARY ACTION/JUDGMENT REPORTING FORM

PLEASE PRINT IN INK OR TYPE

Full Name: ________________________________________________________ Appraiser No. ___________

Mailing Address:

____________________________________________________________________

Residence Address:

____________________________________________________________________

Instructions

Any trainee or real estate appraiser who has had any of the following must report this occurrence to the North

Carolina Appraisal Board within 60 days of final action, pursuant to G.S. 93E-1-12(b)(1).

To report these actions, complete this form and return it to the North Carolina Appraisal Board. Include a certified

copy of the judgment of the court OR order of the licensing agency and a detailed statement in your own words

describing all relevant facts and circumstances.



I have had judgment entered against me regarding an appraisal.



I have had disciplinary actions taken against my trainee registration (or equivalent)/appraiser

license/appraiser certificate in another state.



I have had disciplinary action(s) taken against other professional licenses in North Carolina or another

state.



I have been adjudged mentally incompetent by a court.



I have pled guilty to or been convicted of a criminal offense.

Offense(s)_____________________________________________________________________________________

_____________________________________________________________________________________________

Where_________________________________________________________________Date___________________

(City, State, Other)

Sentence or disciplinary action (including active sentence, suspended sentence, supervised or unsupervised

probation, work release, fine, community service, counseling, license revocation, suspension, reprimand, etc.) or

adjudication of court.

_____________________________________________________________________________________________

Current status of sentence/sanction: ________________________________________________________________

_________________________________________________________________

_____________________

Signature

Date

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