Form Il 505-0347 - Reciprocity Application
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2
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4RECIPROCITY APPLICATION
Office of Banks and Real Estate
500 East Monroe Street, Suite 200
Springfield, IL 62701
PART
I.
APPLICATION FOR THE FOLLOWING PROFESSION
1.
Profession Name for which this application is being completed (Salesperson or Broker).
FEE
$100
PART II.
APPLICANT’S PERSONAL INFORMATION
1.
NAME (L
2.
SOCIAL SECURITY NUMBER
ast , First and Middle)
(Must)
3.
PERMANENT MAILING ADDRESS –
Any change of address must be submitted in writing to the Office of Banks and Real Estate.
Street Address
City, State Zip Code
4.
Maiden, given surname, or any name(s) under which supporting documents will be submitted.
5.
Place of Birth
6.
Date of Birth
7.
Age
8.
Sex
__ __
__ __
__ __
____
____
City, State
Country
Month
Day
Year
9.
Telephone Number(s)
Daytime(_ _ _) _ _ _ - _ _ _ _
Evening(_ _ _) _ _ _ - _ _ _ _
PART III.
Licensure History
Original
Current Status
Profession
State
License Number
Issue Date
Of Original
____
Broker
Licensure
____
Salesperson
State(s) of
____
Broker
Current
____
Salesperson
Licensure
____
Broker
Other State(s) of
____
Salesperson
Licensure
IL 505-0347 (Revised 7/2000)
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