Application For Resident Broker'S License Form
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4Mississippi Real Estate Commission
LeFleur’s Bluff Tower, Suite 300
4780 I-55 North, Jackson, MS 39211
OR
$150.00 FEE
Post Office Box 12685
Jackson, MS 39236-2685
(601) 321-6970 – Telephone * (601) 321-6955 – Fax
APPLICATION FOR RESIDENT BROKER’S LICENSE
1.
Legal name of Applicant ___________________________________________________
Age __________ Sex _________
Name as you want to appear on your license _______________________________________________________________________
Spouse’s Name _____________________________
Marital Status _______________________________________________
2.
Residence Address of Applicant _________________________________________________________________________________
(Number/Street)
(City)
(State)
_______________________________________________________________________________________________________________________________________
(County)
(Zip)
(Home Phone)
(Other Phone)
3.
Physical Business Address of Applicant ___________________________________________________________________________
(Street/Bldg/Suite Number)
(City)
(County)
_______________________________________________________________________________________________________________________________________
(PO Boxy)
(City)
(State)
(Zip)
(Office Phone)
(Office Fax)
4.
Do you understand the requirements of the real estate license laws as to maintaining a definite place of business within Mississippi
and prominent display of your Mississippi Real Estate license? ________________________________________________________
5.
Do you certify that if granted a license, you will comply with the requirements in item # 4? ________ Yes
________ No
6.
Have you ever held a real estate license as a:
BROKER ________ Where? ___________________________________________________________________________________
(Street/Bldg/Suite Number)
(City)
(County) (State)
(From)
(To)
SALESPERSON ______ Where? _______________________________________________________________________________
(Street/Bldg/Suite Number)
(City)
(County)
(State)
(From)
(To)
Please attach Certificates of Licensure from state or states where held.
7.
Have you ever applied for a real estate license in the state of Mississippi?
__________ Yes
__________ No
8.
Have you ever been denied a real estate license in this or any other state?
__________ Yes
__________ No
(If Yes, furnish a statement of details)
9.
Has ANY license ever held by you been revoked or suspended in this or any other state? __________ Yes
__________ No
(This refers to any license for any business or profession regulated by law in this or any other state, district or possession of the United States. If
YES, furnish a statement of details)
10. a.
What has been your business or occupation for the past five (5) years? Give places where employed for sixty (60) days or more and
account for entire time. If self-employed, list nature of your business and address.
________________________________________________________
From ________________ To __________________
(Employer)
(Street & Number)
(City)
(State)
(Month/Year)
(Month/Year)
________________________________________________________
From ________________ To __________________
(Employer)
(Street & Number)
(City)
(State)
(Month/Year)
(Month/Year)
________________________________________________________
From ________________ To __________________
(Employer)
(Street & Number)
(City)
(State)
(Month/Year)
(Month/Year)
Rev. 07/01/2015
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