2001 Salesperson Renewal Duplicate Renewal Printed From Internet Form - Illinois
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2001 SALESPERSON RENEWAL
DUPLICATE RENEWAL PRINTED FROM INTERNET
Start Here--->
LICENSE NO.: __________________________________
SPONSOR LICENSE NO.: ________________________
CHECK HERE IF CHANGE OF ADDRESS
NAME:
______________________________________________
SPONSOR NAME:
ADDRESS: ______________________________________________
____________________________________
ADDRESS LINE 2: ________________________________________
MANAGING BROKER
NAME:
____________________________________
CITY, STATE:
________________________________________
MANAGING BROKER
LICENSE NO:
ZIP:
________________________________________
______________________________
ALL QUESTIONS MUST BE ANSWERED
YES
NO
N/A
(Check only those boxes that apply)
1.
I am more than 30 days in arrears on court ordered Child Support Payments.
2.
I am more than 30 days in arrears on state taxes due to the Illinois Department of Revenue.
3.
I am more than 30 days in arrears on a student loan acquired through the Illinois Student Assistance Commission.
4.
Have you been convicted of a felony which you have NOT previously reported to this office?
5.
Have you had any professional license in this or any other state disciplined and NOT previously reported the action in
writing to this office.
CONTINUING EDUCATION REQUIREMENTS- (CHECK ONE ONLY) (If you are uncertain as to the appropriate box to mark please contact
the licensing section at 217/782-3414.
I certify that I am exempt from the continuing education requirement as my license was issued prior to April 1, 1977 (unless
grandfather exemption has been revoked.)
I certify that I am exempt as this is my first renewal. You will be required to complete 12 hours of continuing education prior to your
renewal in the year 2003.
I HAVE FULLY COMPLIED with the CE requirements for the 2001 renewal period. (CE-MUST be completed prior to submission.)
I AM EXEMPT from the CE requirements delineated in Section 5-70 of the R E Act of 2000. (Attorneys-ARDC#___________________)
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. In addition, my
signature authorizes the Office of Banks and Real Estate to conduct criminal background investigations.
Printed Name____________________________________________________E-mail address_________________________________________
Your Signature___________________________________________________________________________
Social Security Number____________________________________________________________________Sex
M
or
F
Managing Broker Signature________________________________________________________________
PRINT
RESET
Managing Broker License #________________________________________________________________
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