Form Il 505-0347 - Reciprocity Application Page 4
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4GEORGE H. RYAN
WILLIAM A. DARR
OFFICE OF BANKS AND REAL ESTATE
Governor
Commissioner
Bureau of Real Estate Professions
Real Estate Division
Licensing
(217) 782-3414
Education
(217) 782-3338
Consumer Services
(312) 793-8724
General
(217) 785-9300
45 DAY PERMIT SPONSOR CARD
If you will be self-sponsored you must complete the 45-day-permit on your own behalf.
(This form is required to be completed in order to apply for licensure as an Salesperson, Broker or Leasing Agent)
EMPLOYEE INFORMATION
(Note: Must be submitted within 24 hours of Issuance)
CURRENT DATE _________________________
LICENSE NO. ____________________
NAME ___________________________________________SOC SEC NO._____________________
DBA(if applicable) ___________________________________________________________________
MAILING ADDRESS ________________________________________________________________
CITY, COUNTY, STATE, ZIP CODE ___________________________________________________
TELEPHONE NUMBER ( _ _ _ ) _ _ _ - _ _ _ _
SEX________________________
BROKER
SALESPERSON
LEASING AGENT
SPONSOR/FIRM INFORMATION
SPONSOR NAME ___________________________________
LICENSE NO. ___________________
D/B/A (IF APPLICABLE) ______________________________________________________________
MAILING ADDRESS _________________________________________________________________
CITY, STATE, ZIP CODE _____________________________________________________________
TELEPHONE NUMBER ( _ _ _ ) _ _ _ - _ _ _ _
BY __________________________________________________ LICENSE NO. _________________
MANAGING BROKER SIGNATURE
Please retain two copies, (One for Firm's Records and One for the Employee). If you have any questions, please contact our
Licensing Section 217/782-3414.
Return Original To:
Office of Banks and Real Estate
Real Estate Licensing
500 E. Monroe, Suite 200
Springfield, Illinois 62701
IL 505-0347 (Revised 7/2000)
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