Form Il 505-0347 - Reciprocity Application Page 3
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4CERTIFICATION OF LICENSURE HISTORY
Office of Banks and Real Estate
Real Estate Licensing 217/782-3414
COMPLETE ONLY IF YOU ARE/WERE LICENSED IN ANOTHER STATE
APPLICANT:
Complete this section only and forward to the state from which you are requesting certification by a licensing agency/board.
Contact certifying state for appropriate fee. You are authorized to photocopy this form as necessary.
1. Name Last
First
Middle
2. Date of Birth
3. Social Security Number
4. Address Street, City State and Zip Code
5. Maiden or Given Surname
6.
Indicate Profession for Which You Are Applying:
Salesperson______
Broker______
7. Telephone Number:
(__ __ __ ) __ __ __ - __ __ __ __
8.
License Number:
9.
Profession name for which
you are licensed in the other state.
10.
Original Issuance Date
I hereby authorize
to furnish the Office of Banks & Real Estate, Division of Real Estate
Name of State Licensing Agency or Board
the information requested below.
Printed Name
Signature
Date
TO BE COMPLETED BY THE LICENSING AGENCY ONLY:
Other forms of Certification will be accepted, provided all applicable information
requested on this form is contained in the Certification. This completed form MUST be returned directly to the applicant.
CERTIFICATION OF LICENSURE HISTORY
A.
Profession Name
B.
License Number
C.
Issuance Date
D.
Expiration Date
E.
License Status
F.
Reciprocal Registration
Active
Lapsed
Inactive
This State
does
does not have a reciprocal ___
Other (Explain)
agreement with Illinois.
G.
Is there now or has there ever been any disciplinary action commenced against the above applicant
Yes
No
H.
If “G” is answered yes, has there ever been any formal sanctions imposed against the applicant’s license as a matter of public record including but not
limited to fines, reprimand, probation, censure, revocation, suspension, surrender, restriction or limitation?
(If yes, attached a certified copy of disciplinary action.)
Yes
No
I certify that the information contained herein is true and correct according to the official records of this state.
Printed Name
Agency/Board Name, Street, City State, Zip Code and Telephone Number
Signature
Title
Date
EMBOSSED
SEAL
IL 505-0347 (Revised 7/2000)
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