North Carolina Real Estate Commission
P.O. Box 17100, Raleigh, N.C. 27619-7100
Phone (919) 875-3700 • E-mail ra@ncrec.gov
Fax (919) 877-4220 • Website -
CRIMINAL CONVICTION DISCIPLINARY ACTION REPORTING FORM
Instructions
1.
Any real estate broker who is convicted of a misdemeanor or felony criminal offense or who has had any disciplinary action taken
against him or her in connection with any other professional license (real estate or other) must notify the North Carolina Real Estate
Commission in writing within 60 days following the final judgment or final order in the case. [Commission Rule A .0113, eff. August
1, 1996, amended effective July 1, 2000.]
2.
To report a criminal conviction or disciplinary action, complete this form and return to the N.C. Real Estate Commission, Attn: Regulatory
Affairs Division.
3.
Include with this form a certified copy of the judgment of the court or order of the licensing agency and a detailed statement in your
own words describing all relevant facts and circumstances surrounding the conviction/disciplinary action.
4.
For further information concerning reporting criminal convictions or disciplinary actions, contact the Real Estate Commission’s Regulatory
Affairs Division, (919) 875-3700, ext. 131.
(1) Full Name _______________________ ________________________ _________________________________
M
F
First
Middle Name
Last
(2) Physical Address _______________________________________ __________________________ _______ _______________
Street Address or Rural Highway Number
City
State
Zip (9-digit if known)
(3) Mailing _______________________________________________ __________________________ _______ _______________
(If different
P.O. Box or RFD Address
City
State
Zip (9-digit if known)
from above)
(4) License No._________________ (5) Type_______________________ (6) Phone ____________________ ___________________
(Broker or Provisional Broker)
Public
Private
(7) Email Addresses __________________________________________
___________________________________________
Public Email Address
Private Email Address
(8) Date of Birth __________________________________
(9) Offense(s): _______________________________________________________________________________________________
____________________________________________________________________________________________________________
(10) Where: ________________________________ (11) ______________ (12) When:_____________________________________
(County, State, U.S. District, Other)
(File No.)
(Date of Final Judgement/Order)
(13) Sentence or disciplinary sanction (including active sentence, suspended sentence, supervised or unsupervised probation, work release,
fine, community service, counseling, license revocation, suspension, reprimand, censure, etc.): __________________________________
____________________________________________________________________________________________________________
(14) Current status of sentence/sanction: ___________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(15)Signature _________________________________________________ (16) Date_______________________________________
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REC 2.09
1/2016