Asi Form 6609-05 - Dual License Application

DISTRICT OF COLUMBIA

REAL ESTATE BOARD

DUAL LICENSE APPLICATION

(ASI Form 6609-05)

GENERAL INSTRUCTIONS: All applicants must complete every section of this application and submit the original application 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. Mark the type of license you would like in additional to the license(s) you currently hold. 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.

Total Fee Due

Associate Broker (AB)

$240.00

Make fee payable to Assessment Systems Inc.

A charge of $50.00 will be imposed for dishonored checks

(Public Law 89-208)

Independent Broker (IB)

$240.00

Mail form and fee to:

ASI/DC Real Estate Board

MetroPlex II, 8201 Corporate Drive, Suite 400

Principal Broker (PB)

$240.00

Landover, MD 20785

1(888) 204-6192

Property Manager (PM)

$240.00

2A. NAME - If your name has changed, you must provide a notarized copy of the legal name change document (e.g., marriage certificate, divorce decree, etc.)

FIRST NAME

LAST NAME

MI.

TRADE NAME – Independent Brokers and Property Managers ONLY

2B. Social Security Number*

2C. Birthdate

2D. Original License.

(Month)

(Day)

(Year)

(Prefix-

)

(License Number)

SP, PB, AB, IB, PM

3A. RESIDENTIAL ADDRESS— A street address MUST be provided.

STREET ADDRESS LINE 1 (If applicable, use this line to indicate APARTMENT, SUITE, or FLOOR#)

STREET ADDRESS LINE 2 (Use this line to indicate STREET NUMBER and STREET NAME)

CITY

STATE

ZIP CODE

AREA CODE – RESIDENTIAL PHONE NUMBER

AREA CODE – RESIDENTIAL FAX NUMBER

3B. BUSINESS ADDRESS (Broker Companies, Independent Brokers, and Property Managers ONLY). A street address MUST be provided.

STREET ADDRESS LINE 1 (If applicable, use this line to indicate APARTMENT, SUITE, or FLOOR #)

STREET ADDRESS LINE 2 (If applicable, use this line to indicate STREET NUMBER and STREET NAME)

CITY

STATE

ZIP CODE

AREA CODE – BUSINESS PHONE NUMBER

AREA CODE – BUSINESS FAX NUMBER

*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.