Application For Resident Salesperson License Form printable pdf download

Mississippi Real Estate Commission

LeFleur’s Bluff Tower, Suite 300

4780 I-55 North, Jackson, MS 39211

$120.00 FEE

Post Office Box 12685

Jackson, MS 39236-2685

(601) 321-6970 – Telephone * (601) 321-6955 – Fax

APPLICATION FOR RESIDENT SALESPERSON LICENSE

1. Legal name of Applicant _____________________________________________________________Age________ Sex_________

Name as you want to appear on your license: _____________________________________________________________________

2. Residence Address of Applicant_______________________________________________________________________________

(Number/Street)

(City)

____________________________________________________________________________________________________________________________________

(County)

(State)

(Zip)

(Home Phone)

(Other Phone)

3. Marital Status ____________________________________Spouse’s Name ____________________________________________

4. Name Of Employer to be designated on license___________________________________________________________________

(Broker, Company, etc.)

4A. Physical address of Employer________________________________________________________________________________

(Street and Number)

_____________________________________________________________________________________________________________________________

(P.O. Box)

_____________________________________________________________________________________________________________________________

(City)

(County)

(State)

(Zip Code)

(Telephone Number)

5. Have you ever held a real estate License in Mississippi or any other state? Yes______ No______

(If answer is yes, please attach certification of licensure.)

A Broker______ Where______________________________________________________________________________________

(Street and No.)

(City)

(County)

(State)

(From)

(To)

A Salesperson_______ Where_________________________________________________________________________________

(Street and No.)

(City)

(County)

(State)

(From)

(To)

6. Have you ever before applied for a real estate License in the State of Mississippi? Yes________ No________

(If answer is “Yes” furnish statement of details)

7. Have you ever been denied a real estate license in this or any other state? Yes____ No____

8. Has ANY license ever held by you been revoked or suspended, in this or any other state? Yes____ No____

(If answer is “Yes” furnish

statement of details) (This refers on any license for any business or profession regulated by law in this or any other state, or district or possession of the United States.)

9. What has been your business or occupation for past five years? Give places where employed for sixty days or more, and account

for entire time. If self-employed, list nature of business and address.

_______________________________________________________ From_________________ To______________

(Employer)

(Street & Number)

(City)

(State)

(Mo. & Yr.)

_______________________________________________________ From_________________ To______________

(Employer)

(Street & Number)

(City)

(State)

(Mo. & Yr.)

_______________________________________________________ From_________________ To______________

(Employer)

(Street & Number)

(City)

(State)

(Mo. & Yr.)

_______________________________________________________ From_________________ To______________

(Employer)

(Street & Number)

(City)

(State)

(Mo. & Yr.)

10. Years Education (Circle highest school year completed)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Rev. 07/01/2015

Application For Resident Salesperson License Form

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