Application For Resident Broker'S License Form Page 2
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1
2
3
410.b.
Give complete summary of real estate experience, advise whether or not you have operated under a City or County Real Estate
Privilege Licensure, where obtained and the date or dates of purchase. Disclose all states in which you have held or currently hold a
real estate license and furnish a Certification of Licensure from the state or states.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
11.
What business, other than real estate, do you expect to engage in and what is the address thereof? _____________________________
12.
State if you have ever been convicted of any criminal offense. _____ Yes
_____ No
(If Yes, furnish details)
13.a.
Has anyone ever obtained a judgment against you in any court involving real estate? ______ Yes ______ No
(If Yes, furnish details)
13.b.
Taken bankruptcy? __________ Yes __________ No
(If Yes, furnish petition for voluntary bankruptcy, schedules and discharge)
14.
Are you an American Citizen? __________ Yes __________ No
If not, how long have you lived in the United States? ___________________
15.
When were you born? ____________________
Where __________________________________________________________
(Mo.
Day Yr.)
(City)
(State)
(County)
16.
How long, immediately prior to date of execution of this application, have you been a resident of Mississippi? ___________________
17.
Give the name of the city, county and state where you are registered to vote. ______________________________________________
(City)
(State)
(County)
18.
Social Security Number
_________________________________
Do you have a Mississippi Driver’s license? _____ Yes ______ No
19.
If Yes, furnish number ___________________________
If No, please explain __________________________________________________________________________________________
20.
Have you ever purchases a Mississippi Car Tag? _______ Yes _______ No
If Yes, furnish number _____________________
21.
Did you file a Mississippi Income Tax Return last year? _______ Yes _______ No
If No, please explain __________________________________________________________________________________________
22.
Give the name and addresses of the banks you have accounts with.
_______________________________________________________________________________________________________________________________________
(Bank)
(Street & Number)
(City)
(State)
(Zip)
(
) Checking
(
) Savings
(
) Loans
(
) Credit Cards
_______________________________________________________________________________________________________________________________________
(Bank)
(Street & Number)
(City)
(State)
(Zip)
(
) Checking
(
) Savings
(
) Loans
(
) Credit Cards
_______________________________________________________________________________________________________________________________________
(Bank)
(Street & Number)
(City)
(State)
(Zip)
(
) Checking
(
) Savings
(
) Loans
(
) Credit Cards
AFFIDAVIT
(READ CAREFULLY)
The undersigned, in making this application to the Mississippi Real Estate Commission for license to carry on the business of real estate Broker under the
provisions of the Mississippi Real Estate Broker’s License Act of 1954, as Amended, swears (or affirms) that he/she has read and is thoroughly familiar with
the provisions of the aforementioned Act, and Rules and Regulations issued by the Commission, and agrees to comply fully with them. The undersigned
further swears (or affirms) that all of the information given in this application is true and correct to the best of his/her knowledge and belief. Under Section 73-
35-5 (3) his/her application and other information submitted to this Commission may be reviewed by members of the general public under reasonable rule and
regulations shall be prescribed by the Commission. I hereby authorize any financial institution, educational institution, or any other agency, public or private,
federal or state, to release any information contained in their files to the Mississippi Real Estate Commission.
Signature of Applicant ____________________________________________
Subscribed and sworn to before me, this __________ day of ________________________ 20 __________.
My Commission expires ___________________________________________
________________________________________________________________
Notary Public
County
State
Rev. 07/01/2015
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