Form 45664 - Application For Real Estate Appraiser Permit For Temporary Practice - Indiana Professional Licensing Agency

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APPLICATION FOR REAL ESTATE APPRAISER
Indiana Professional Licensing Agency
PERMIT FOR TEMPORARY PRACTICE
302 W. Washington Street, Room E034
Indianapolis, IN 46204
Sta te Form 4 5664 (R5 / 2-03 )
Telephone: (317) 232-2980
Appro ved by State Bo ard of Accounts, 2003
FOR OFFICE USE ONLY
INSTRUCTIONS: 1. Type or print in ink.
Permit nu mb er
2. Applicant must read Real Estate Appraiser Licensure and Certification statute and rules before
FEE: $50.00
completing and filing the application.
3. Pay the fee of $50.00 (fee is nonrefundable and nontransferable pursuant to IC 25-1-8-2(e)).
A pplication for Pe rmit for Tempora ry Practice for:
Indiana licensed residential appraiser
Indiana certified residential appraiser
Indiana certified general appraiser
Have yo u e ver ap plied to the In diana Real Esta te App raiser Lice nsure and Certi fication Board for a permit for tempor ary pra ctice?
Yes
No
If yes, how ma ny time s previou s to this ap plicati on and th e issuance date(s)?
Pursuant to 876 IAC 3-3-21, the board will recognize, on a temporary basis, the license or certificate of an appraiser issued by another state, providing the
following:
1. The appraiser's business is of a temporary nature.
2. The appraiser registers with the board; and
3. The license or certificate issued by the other state is appropriate for the type of property to be appraised.
Each temporary license or certificate is limited to performing the appraisals or specialized services required by the contract for appraisal services. Temporary
privileges expire upon the completion of the work required by the assignment or specialized service, or after six (6) months, whichever is earlier. No more than
three (3) different temporary licenses may be issued per calendar year. An applicant may not advertise or hold out as an Indiana licensed or certified appraiser.
The appraiser agrees to abide by the Indiana statute and rules regulating appraisers. By filing this application, the applicant hereby consents to service of process
in Indiana. A document attesting to licensure from the board in the state or states in which the appraiser is licensed shall accompany this application.
(Letter of good standing)
Da te (month, da y, year)
Name of ap plicant (first, mid dle, last)
Name of ap praisal business
A ppraisal business maili ng address (n umber and stree t, city, state and ZIP code)
Social Security n umber *
Tele phone nu mb er
* You Social Security number is mandatory in accordance with
(
)
IC 4-1-8-1. This record cannot be processed without it.
ASSIGNMENT INFORMATION
A ssignmen t addre ss (number and str eet, city, street, ZIP code)
Description of pro perty (numbe r of units, size, site d escrip tion , type ; retail, multi-fa mi ly, industrial, e tc.)
Date project will begin (mon th, day, year)
Ho w long will yo ur assign men t ta ke ? (in dicate da ys, weeks, or mo nth s)
CURRENT EMPLOYER
Name of company
A ddress (n umb er and stree t, city, state, ZIP code )
Te lephon e n umber
(
)
LICENSURE STATUS
Type of license you hold
License i ssued by the sta te of:
Have yo u b een denie d a n a ppraiser license or denied ad mission to an ap praiser examination by this state or any oth er state?
Yes
No
(If yes, provide a copy o f the licensing bo ard denia l)
Have yo u h ad an apprai ser license su sp ended or revoked by this state o r an y other state?
Yes
No
(If yes, provide a copy o f the licensing bo ard order )
Have yo u e ver be en con victed of a cr ime ?
Yes
No
(If yes, pr ovi de a copy of the cou rt orde r, a ny pe rtin ent documen ts, and a written explan atio n o f th e circumstan ces.)
Do you understand th at continuing to practice app raising after th e e xp iration date o f th e P ermit fo r Tempor ary Pra ctice i s a vio latio n?
Yes
No
(over)

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