Form 339 (R7 / 8-98) - Application For Renewal Of Real Estate License - Professional Licensing Agency, State Of Indiana

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APPLICATION FOR RENEWAL OF
BRING CASH PAYMENTS IN PERSON TO:
REAL ESTATE LICENSE
INDIANA PROFESSIONAL LICENSING AGENCY
Indiana Government Center South
State Form 339 (R7 / 8-98)
302 W. Washington St., Rm. E034
Approved by State Board of Accounts, l998
Indianapolis, IN 46204-2700
Telephone: (317) 232-2980
INSTRUCTIONS:
Tear along perforation below and return with check or money order to the indicated address.
FAILURE TO RENEW BY THE EXPIRATION DATE BELOW WILL RESULT IN A DELINQUENT FEE ALLOWED IN THE INDIANA STATUTES OR
BOARD RULES.
To be valid (a) this must be signed in ink and (b) if the Social Security or Federal I.D. number is not entered you are requested to supply it.
THIS APPLICATION IS FOR RENEWAL FOR
FOR THE PERIOD ENDING
ADDRESS
RESTORATION /
LICENSE
EXPIRATION
RENEWAL
TYPE OF LICENSE
DELINQUENT
TOTAL
NUMBER
DATE
FEE
FEE
PAY THIS AMOUNT BEFORE
Make check or money order payable and mail to:
TEAR AT THE PERFORATION AND RETURN WITH REMITTANCE
PLEASE DO NOT FOLD
l
I HEREBY APPLY FOR RENEWAL OF THE AFORESAID LICENSE NUMBER(S)
Signature of applicant
CONTINUING EDUCATION
Total hours received: _________
Social Security number *
I HEREBY ATTEST THAT I HAVE SUCCESS-
* Your Social Security number
FULLY COMPLETED THE ABOVE HOURS
is mandatory under IC 4-1-8-1.
AS REQUIRED PER IC 25-34.1-9-9 to 11.
ADDRESS
Signature
Date (month, day, year)
SEE REVERSE SIDE
(
)

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