Form Re-620-170 - Application For Certification As A Real Estate Appraiser Page 2
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5Personal data
If any of the following questions are answered YES, full details must be furnished on a separate (8 1/2" x 11") sheet and
attached to this application.
YES
NO
1.
With the exception of motor vehicle violations, have you ever been convicted of a crime, felony, or
misdemeanor by this state, any other state, the federal government, or any other jurisdiction within the
past ten years?
2.
Has any application for a professional or occupational license or permit made by you ever been denied,
or has a license or permit issued to you ever been suspended, revoked, censured, or fined, in this state
or any other jurisdiction?
3.
Have you ever had a civil court order, verdict, or judgement entered against you in any court or competent
jurisdiction in which the subject matter involved any real estate or business related activity? Have you
ever entered a plea of nolo contendere?
4.
Have you ever used any name other than the one herein given, either initials, surname, maiden name,
or alias?
Qualifying experience and general work history
1.
Total number of hours of experience in residential real estate appraising:
2.
Total number of hours of experience in non-residential real estate appraising:
List in chronological order all real estate appraiser work experience. If you are (or have been) self-employed, and the
sole proprietor of the company, please list the company name and enter "self" under "Employer or Supervisor." You
may attach additional pages if necessary.
NAME OF COMPANY
YOUR TITLE/POSITION
COMPANY PHONE
EMPLOYER/SUPERVISOR NAME
COMPANY ADDRESS
DATES (from-to)
MONTHLY HOURS
TOTAL HOURS
DUTIES
NAME OF COMPANY
YOUR TITLE/POSITION
COMPANY PHONE
EMPLOYER/SUPERVISOR NAME
DATES (from-to)
COMPANY ADDRESS
MONTHLY HOURS
TOTAL HOURS
DUTIES
NAME OF COMPANY
YOUR TITLE/POSITION
COMPANY PHONE
EMPLOYER/SUPERVISOR NAME
COMPANY ADDRESS
DATES (from-to)
MONTHLY HOURS
TOTAL HOURS
DUTIES
NAME OF COMPANY
YOUR TITLE/POSITION
COMPANY PHONE
EMPLOYER/SUPERVISOR NAME
DATES (from-to)
COMPANY ADDRESS
MONTHLY HOURS
TOTAL HOURS
DUTIES
RE-620-170 RE APPRAISER APP. (R/1/99)M/W Page 2 of 5
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