REAL ESTATAE CONTINUING EDUCATION INSTRUCTOR
CODE 163
Important Notice: Completion of this form is necessary to
OFFICE OF BANKS AND REAL ESTATE
accomplish the requirements outlined in The Real Estate
500 East Monroe, Suite 200
License Act of 2000.
Disclosure of this information is
Springfield, IL 62701
REQUIRED. Failure to comply may result in this form not
being processed. This form has been approved by the Forms
REAL ESTATE EDUCATION 217/ 782-3338
Management Center.
3. Social Security Number.
1. Name
Last
First
Middle
2. Date of Birth
_ _ / _ _ / _ _
_ _ _ - _ _ - _ _ _ _
Month Date Year
4. Address (Include Street, City, State and Zip Code)
5. Work Telephone Number
(Include Area Code)
( _ _ _ ) _ _ _ - _ _ _ _
6. Are you and an approved Real Estate Prelicensing course instructor in Illinois or another
7. Home Telephone Number
(Include Area Code)
1 1
1 1
jurisdiction?
Yes
No
( _ _ _ ) _ _ _ - _ _ _ _
If “Yes” Certificate/License No.:
8. List courses you plan to teach -- approval of this instructor application does not guarantee approval of any specific course. All
courses must be approved separately under submission to the Office of Banks and Real Estate by an approved continuing education
sponsor.
9. Personal History Information
1 1 YES
q q NO
Are you more than 30 days in arrears on any court ordered Child Support
Payments?
q q YES
w w NO
Have you ever been convicted of a crime which you have not previously reported in
writing to this office?
q q YES
w w NO
Have you had any professional license or permit in this or any other jurisdiction
disciplined and not previously reported the action in writing to this office?
q q YES
w w NO
Are you in arrears on any state taxes due to the Illinois Department of Revenue?
q q YES
w w NO
Are you in arrears on any Student loan acquired through the Illinois Student
Assistance Commission?
IL 505-0339
rev(1)1097
1