Form Il 505-0347 - Reciprocity Application (Page 2 of 4) in pdf

PART IV.

PERSONAL HISTORY QUESTIONS (ALL MUST BE ANSWERED)

YES

Are you a high school graduate or have you received a G.E.D.?

Have you ever been convicted in ANY state or federal jurisdiction, including military courts, of a felony or any

crime which an essential element is dishonesty?

Have you ever held, or do you currently hold, a real estate license in Illinois or any other jurisdiction?

Have you been denied a professional license or permit or the privilege of taking an examination?

Have you ever had a professional license or permit disciplined in any way by any licensing authority in

Illinois or any other state/jurisdiction?

Have you ever been discharged other than honorable from the armed service or from a city, county,

state or federal position?

Are you more than 30 days in arrears on any court ordered child support payments?

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

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

PART V.

EXPERIENCE VERIFICATION- This must be completed and signed by your sponsoring broker.

Applicant Name

Last

First

Middle

Sponsoring Broker Name

License Number

Firm Address

Street

City, State and Zip

Firm License Number (if applicable)

Firm Telephone Number

Date of Employment

From

__ __/__ __/__ __

To __ __/__ __/__ __

month/day/year

Please provide a brief description of the license activities performed by the applicant.

Under penalties of perjury, I hereby declare that this information is true and correct.

Sponsoring Broker’s Name (Printed)

Signature

Date

PART VI.

NON-RESIDENT CONSENT/CERTIFYING STATEMENT

I hereby consent with the OBRE that actions may be commenced against me in a court of competent jurisdiction in this State by the service of summons,

process, or other pleading authorized by the law upon the Commissioner. The consent shall stipulate and agree that service of the process, summons, or

pleading upon the Commissioner shall be taken and held in all courts to be valid and binding as if actual service had been made upon the applicant in Illinois.

CERTIFYING STATEMENTS

I hereby attest to having read and understood the Illinois Real Estate Licensing Act of 2000, Rules and agree to abide by all provisions contained therein. I hereby

submit this application, and upon oath states and verifies that all statements made are true, correct and are made for the purpose of securing a license under the Real

Estate License Act of 2000.

Typed/Printed Name of Applicant

Date

Signature of Applicant

IL 505-0347 (Revised 7/2000)