Initial Broker License Application Form - Louisiana Real Estate Commission

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Louisiana Real Estate Commission
Post Office Box 14785
Baton Rouge, LA 70898-4785
1-800-821-4529 (in state only) or (225) 925-1923
INITIAL BROKER LICENSE APPLICATION ___ Resident ___ Non-resident
Initial broker license fee remit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $120.00
Add Research and Education Fund Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00
Add Recovery Fund Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10.00
Add Application Processing Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.00
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $165.00
(Remit total payment of $165.00 to the Louisiana Real Estate Commission. Checks are accepted.)
Important: If you intend to operate under a trade name, you must provide this office with a copy of the certificate
of registration issued by the Louisiana Secretary of State before your license will be issued in that name. Once you
have obtained your individual broker license, you are eligible to become the qualifying broker for an unlimited
number of corporations, partnerships, and limited liability companies. Application forms for these additional
licenses may be obtained by contacting the Louisiana Real Estate Commission.
1. Type of license:
Individual
Associate Broker
2. Name: _____________________________________________________________________________
(First)
(Middle)
(Last)
3. Resident of: Parish/County: __________________________________________________________
4. Physical Address: ___________________________________________________________________
(Mandatory)
(Street)
(City)
(State)
(Zip)
5. Mailing Address: ____________________________________________________________________
(If different from Physical)
(Street)
(City)
(State)
(Zip)
6. Business Telephone: (_____)___________________ Home Phone: (_____)_____________________
7. Date of Birth:
/
/
Male
Female
8. Are you an American citizen?
Yes
No If no, list Alien registration number: _________________
9. Have you ever been licensed as a salesperson or broker in Louisiana or any other state?
Yes
No
List the name(s), date(s), and state(s) in which each license was issued. Use attachment if necessary:
(a) ______________________________________________________________________________
(b) ______________________________________________________________________________
(c)________________________________________________________________________________
You must attach a license verification form from each state in which you were previously licensed.
10. Have you ever had a salesperson or broker license denied, censured, suspended, or revoked in
Louisiana or any other state?
If yes, furnish letter of detail with this application.
Yes
No
11. Have you ever been convicted, pled guilty or nolo contendere to the crimes of forgery, embezzlement,
obtaining money under false pretenses, larceny, extortion, conspiracy to defraud, theft, or any crime
of moral turpitude?
If yes, furnish letter of detail with this application.
Yes
No
12. Have you ever been convicted, pled guilty or nolo contendere to any felony crime in any court of
competent jurisdiction?
If yes, furnish letter of detail with this application.
Yes
No
13. Name the institution from which you received your high school diploma or certificate of equivalency:
_________________________________________________________________________________________
Institution
City
State
Date Graduated
14. Attach proof (certificates and/or transcripts) of 150 hours of prerequisite course work approved by the
Louisiana Real Estate Commission.
NOTE: This may not include hours previously used to meet the educational
requirement for a salesperson license. Please direct questions concerning course work to the Education Division.

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