Form Rec 1.45 - Nonresident Supplement To The Application For Real Estate License - North Carolina Real Estate Commission Page 2

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Section 2 - Declaration of Company Status (Applicants for a NON-PROVISIONAL Broker License Only)
I, the undersigned, certify that I will, when properly licensed as a NON-PROVISIONAL real estate broker by the North
Carolina Real Estate Commission, engage in the real estate brokerage business in North Carolina as a/an (check one):
Broker Affiliated with:__________________________________________________________________________
(Name of NC Licensed Broker or Firm)
[If employing broker or firm is not known at the time of application, indicate “Unknown” in the above space.
You must promptly notify the Commission upon your affiliation with a NC broker or firm.]
Sole Proprietorship [Business owned solely by the applicant.]
Name of Business:_____________________________________________________________________________
Firm [Corporation, Limited Liability Company, Partnership, Association or other Business Entity (other than
a Sole Proprietorship) that is owned wholly or in part by the applicant.]
Name of Firm:________________________________________________________________________________
NOTE: If you check “Firm”, a real estate firm license must be acquired prior to or concurrent with individual
licensure. Application form is available on the Commission website. If you must take the licensing exam to obtain
your North Carolina license, you must obtain your individual broker license prior to submitting your firm license
application.
Section 3 - Consent to Service of Process and Pleadings
Know all men by these presents:
Pursuant to the requirements of Chapter 93A of the General Statutes of North Carolina, the undersigned
individual does hereby irrevocably consent, stipulate and agree that suits, actions and administrative proceedings may
be commenced against such individual in the courts and agencies of this State, by the service of any process or pleading
authorized by the laws of this State on the Executive Director of the North Carolina Real Estate Commission, and that
service of such process or pleadings on said Director shall be taken and held in all courts to be as valid and binding as
if the service had been made upon said individual in the State of North Carolina.
Signature_________________________________________________________________ Date_______________

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