State Board Of Certified Real Estate Appraisers Form 2013 (Page 2 of 2) in pdf

State Board Of Certified Real Estate Appraisers Form 2013 Page 2

70 AMC-ADD/NAME 10/13

SECTION 2: SECONDARY INFORMATION

1. STATE OR PLACE OF INCORPORATION OR

ORGANIZATION

2. IF NOT AN INDIVIDUAL AND INCORPORATED OR

OTHERWISE FORMED UNDER THE LAWS OF A

JURISDICTION OTHER THAN THE COMMONWEALTH

OF PENNSYLVANIA, ALSO SUBMIT

DOCUMENTATION THAT STATES YOU ARE

AUTHORIZED TO TRANSACT BUSINESS IN THIS

COMMONWEALTH.

3. FICTITIOUS NAME, IF ANY

4. WEBSITE ADDRESS

5. FAX NUMBER

6. LIST EACH STATE OR JURISDICTIONS IN WHICH

APPLICANT IS REGISTERED AS AN APPRAISAL

MANAGEMENT COMPANY. ATTACH SEPARATE

PAGE, IF NEEDED

7. MONTH AND YEAR APPLICANT BEGAN OFFERING

APPRAISAL MANAGEMENT SERVICES IN

PENNSYLVANIA.

SECTION 3: CERTIFICATION STATEMENT

BY SIGNING BELOW, I VERIFY THAT THIS FORM IS IN THE ORIGINAL FORMAT AS SUPPLIED BY THE

DEPARTMENT OF STATE AND HAS NOT BEEN ALTERED OR OTHERWISE MODIFIED IN ANY WAY. I AM AWARE

OF THE CRIMINAL PENALTIES FOR TAMPERING WITH PUBLIC RECORDS OR INFORMATION PURSUANT TO 18

Pa. C.S.§49.11.

ADDITIONALLY, I CERTIFY THAT THE STATEMENTS IN THIS APPLICATION ARE TRUE AND CORRECT TO THE

BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF, AND THAT I AM OF GOOD MORAL CHARACTER. I

UNDERSTAND THAT ANY FALSE STATEMENT MADE IS SUBJECT TO THE PENALTIES OF 18 Pa. C.S.§4904

RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES AND MAY RESULT IN THE SUSPENSION OR

REVOCATION OF MY LICENSE OR CERTIFICATE.

COMPLIANCE PERSON SIGNATURE_______________________________________________________ DATE ___________

PAGE 2 OF 2

State Board Of Certified Real Estate Appraisers Form 2013 Page 2