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NAME________________________________

OFFICE OF BANKS AND REAL ESTATE

Restoration Application-Salesperson, Broker or Leasing Agent

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[___]

Type or print in black ink only. Send only check or money order. Make remittance payable to the Office of Banks and Real Estate. Fee is

non-refundable. The fee includes a penalty fee of $50.00, sponsor card fee of $25.00 plus all lapsed renewal fees. Complete the 45-

DAY-PERMIT SPONSOR/FIRM INFORMATION. In addition Brokers are required to complete the CONSENT TO

EXAMINE AND AUDIT. Failure to complete all forms attached, in entirety, will cause a delay in processing your restoration.

Name change must be accompanied with proof. (i.e.; Copy of marriage license, divorce decree, court ordered or amended articles, etc.)

Send application, remittance and all attachments to the address listed below. If you have any questions, please contact our office at

217/782-3414 between 9:00 am and 4:00 p.m.

Office of Banks and Real Estate

Real Estate Licensing Division

500 East Monroe, Suite 200

Springfield, IL 62701

You are required to submit proof of the following documentation indicated below:

Proof of completion of your 12 hours of continuing education obtained through an approved provider. This MUST be in the

form of attendance slips.

Attorneys-Submit copy of current ARDC card OR

Not Applicable

License Number:

Applicant's Name:

Indicate Mailing Address:

Processor:

Date:

Expiration Date of License: ______________________

Social Security No:________________________________________

Total Fee Due:_________________________________

ALL PERSONAL HISTORY QUESTIONS MUST BE ANSWERED

YES

Are you more than 30 days in arrears on any court ordered Child Support Payments?

YES

Have you ever been convicted in ANY state, federal or military jurisdiction, of a felony or a crime of which

an essential element is dishonesty, that you have not previously reported in writing to this office?

YES

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?

YES

Are you in arrears on any state taxes due to the Illinois Department of Revenue?

YES

Are you in arrears on any Student loan acquired through the Illinois Student Assistance Commission.

I understand that if I provide false/fraudulent information, I could lose my license, be fined or have other penalties assessed. Therefore, I declare

that I have examined this form and to the best of my knowledge, all statements are true, correct and accurate.

My signature authorizes a representative of the Office of Banks and Real Estate to examine and audit special accounts that I maintain. In

addition, my signature authorizes the Office of Banks and Real Estate to conduct criminal background investigations.

Your Signature: __________________________________________________________Date:___________________

Managing Broker's Signature:_______________________________________________Date:____________________

IL 505-0350 Revised (7/2000)

Form Il 505-0350 - Restoration Application-Salesperson, Broker Or Leasing Agent - Illinois Office Of Banks And Real Estate

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