North Carolina Real Estate Commission
P. O. Box 17100, Raleigh, N.C. 27619-7100
(919) 875-3700 Fax (919) 877-4216
TO THE APPLICATION FOR REAL ESTATE LICENSE
This form is NOT a license application. It is only a “supplement” to be submitted by nonresident applicants for a North Carolina
license IN ADDITION TO the license application. Do not submit this form without the license application.
TYPE OR PRINT IN BLACK INK
Name Shown on License Application __________________________________________________________________
Section 1 - Affidavit of Residency
I am a legal resident of the State of_________________________________________________________________
I have resided in said state since___________________________________________________________________
I declare my residence at________________________________________________________________________
(Street Address or Highway)
to be my one true, fixed, and permanent home (place of domicile) to which I intend to return after any absence or after
temporarily residing elsewhere.
[Applicant may have only one legal residence.]
do NOT own the residence shown in Item 1 above.
I am registered to vote in___________________ County of the above-named state.
The phone number of the county Board of Elections is (____)____________________ .
My personal vehicle is registered in the State of ______________________________.
I have a driver’s license in the following state(s):____________________________________________________ .
I paid income taxes for the last tax year in the following state(s):_______________________________________ .
The following two (2) residents of the community where I maintain my legal residence are well known to me and can
attest that I am a permanent resident of that community.
Note: Attach a separate letter explaining any inconsistency in the answers provided above or on the application form.