Asi Form 6609-03 - New License Application - Broker Companies Only

DISTRICT OF COLUMBIA

REAL ESTATE BOARD

NEW LICENSE APPLICATION – BROKER COMPANIES ONLY

(ASI Form 6609-03)

GENERAL INSTRUCTIONS

All applicants must complete every section of this application (front and back) and submit the original application and all required supporting documents

with the total fee due. False or misleading statements will be cause for disciplinary action and could be cause for criminal prosecution pursuant to DC

Code 22-2514. If more space is needed to fully answer questions, attach additional sheets. If you have any questions, call ASI Customer Service at 888-

204-6192.

1. TYPE OF APPLICATION AND FEES

. Check the box next to the type of company that best represents your company’ s structure. This

form will be returned unprocessed if the fee is not included or if the fee is less than required. Make check or money order payable to: Assessment

Systems, Inc. CASH PAYMENTS WILL NOT BE ACCEPTED.

Corporation

Limited Liability Company (LLC)

Date of incorporation________________

Partnership

State of incorporation________________

TOTAL FEE DUE = $135.00

MAKE FEE PAYABLE TO ASSESSMENT SYSTEMS, INC.

A charge of $50.00 will be imposed for dishonored checks (Public Law 89-208)

2A. NAME. Enter company name exactly as it should appear on the license, leaving a space between each word. Include

the Company’ s Certificate of Authority showing this name.

COMPANY NAME

2B. FEDERAL EMPLOYEE IDENTIFICATION NUMBER (FEIN)*

-

3. BUSINESS ADDRESS.

Please enter the address of your main office or headquarters below. If you have branch offices, please list their

addresses on a separate sheet of paper and submit with this application. A street address MUST be provided. If

applicable choose only one box below and write the number in the boxes provided.

APARTMENT

SUITE

ROOM

FLOOR NUMBER

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

-

CITY

STATE

ZIP CODE

-

-

AREA CODE

BUSINESS PHONE NUMBER

AREA CODE

BUSINESS FAX NUMBER

4. SUPPORTING DOCUMENT

ASI ONLY

The following document must be submitted with the application. Please indicate whether it has been enclosed.

This document must be obtained from the District of Columbia Corporations Division:

YES

NO

Certificate of Authority (Letter of Good Standing)

MAIL FORM AND FEE TO:

ASI/DC Real Estate Board

PO Box 13805 • Philadelphia, PA 19101-3805

*Under the authority of Public Law 93-579 Section 7(b), the Department of Consumer and Regulatory Affairs requests your Social Security Number/FEIN to assist in the administration of D.C. tax laws. Disclosure is not required as part of the

licensing process and will not be made available to the public.