Form Il 505-0340 - Certification By Licensing Agency /board

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CERTIFICATION BY LICENSING AGENCY /BOARD
ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
Division of Professional Regulation / Real Estate Professions Section
320 West Washington Street
Springfield, IL 62786
REAL ESTATE LICENSING 217/ 782-3414
APPLICANT:
Complete this section only. Forward it to the state from which you are requesting certification by a
licensing agency/board. Contact certifying state for appropriate fee. You are authorized to photocopy
this form as necessary.
1. Name
Last
First
Middle
2. Date of Birth
3. Social Security Number.
_ _ /
_ _ / _ _
_ _ _ / _ _ / _ _ _ _
Month Day Year
4. Address Street, City, State, Zip Code
5. Maiden or Given Surname
6. Indicate Profession Name for Which You Are Applying:
Salesperson
Broker
Instructor
7a. Name of Profession as it appears on license from the state to which
7b. License Number
this form is being forwarded.
7c. Issuance Date of License
7d. Licensed by
Examination
Reciprocity
I hereby authorize _____________________________________________________ to furnish to the Illinois Department of Financial
Name of State Licensing Agency or Board
and Professional Regulation, the information requested below.
Signature of Applicant:
Date:
Other forms of Certification will be accepted, provided all applicable information requested
LICENSING AGENCY:
on this form is contained in the Certification, Return completed form directly to the
applicant.
CERTIFICATION OF LICENSE
A. Name of Profession as it appears on license
B. License Number
C. Issuance Date of License
D. Expiration Date of License
E. Current License Status
F. Reciprocal Registration
Active
Lapsed
Inactive
This State
does
does not have a reciprocal
agreement with Illinois.
Other (Explain) __________________________________
G. Is there now or has there ever been any disciplinary action commenced against the applicant?
Yes
No
H. If “G” is answered yes, has there ever been any formal sanctions imposed against the applicant’s license as a matter of public record
including but not limited to fine, reprimand, probation, censure, revocation, suspension, surrender, restriction or limitation?
(If yes, attach a certified copy of disciplinary action.)
Yes
No
I certify that the information contained herein is true and correct according to the official records of this state.
Agency/ Board Street Address, City, State, Zip Code
Signature
and Telephone Number
Print Name
Title
Date
EMBOSSED
SEAL
IL 505-0340 (Rev 3/10)

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