Form Rec 1.45 - Nonresident Supplement To The Application For Real Estate License - North Carolina Real Estate Commission

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North Carolina Real Estate Commission
P. O. Box 17100, Raleigh, N.C. 27619-7100
(919) 875-3700 Fax (919) 877-4216
NONRESIDENT SUPPLEMENT
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
1.
I am a legal resident of the State of_________________________________________________________________
I have resided in said state since___________________________________________________________________
(Month)
(Year)
I declare my residence at________________________________________________________________________
(Street Address or Highway)
___________________________________________________________________________________________
(City)
(State)
(Zip)
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.]
2.
I
own
do NOT own the residence shown in Item 1 above.
3.
I am registered to vote in___________________ County of the above-named state.
The phone number of the county Board of Elections is (____)____________________ .
4.
My personal vehicle is registered in the State of ______________________________.
5.
I have a driver’s license in the following state(s):____________________________________________________ .
6.
I paid income taxes for the last tax year in the following state(s):_______________________________________ .
7.
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.
___________________________________________________________________________________________
(Name)
(Address)
(Phone)
___________________________________________________________________________________________
(Name)
(Address)
(Phone)
Note: Attach a separate letter explaining any inconsistency in the answers provided above or on the application form.
OVER
REC 1.45
REV 4/16

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