Form 45664 - Application For Real Estate Appraiser Permit For Temporary Practice (Page 2 of 2) in pdf

If your answer is “Yes” to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location,

date and disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation

of a license or permit issued pursuant to this application.

1. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state,

or by the Federal courts, or any agency of the government, or are criminal charges now pending against you?

Yes

(Except for minor violations of traffic laws resulting in fines)

2. Have you ever been denied a license, certification, registration, or permit to practice real estate appraising or any

Yes

other profession in this or any other state?

3. Has any complaint been filed against you in the state of Indiana, or in any other state, regarding any professional

Yes

license you currently hold or have previously held?

4. Has disciplinary action ever been taken regarding any professional license, certification, registration, or permit that

Yes

you currently hold or have previously held?

5. Do you understand that continuing to practice appraising in Indiana after the completion of the assignment for which

Yes

this temporary permit was issued is a violation of Indiana Code 25-34.1-8-12?

APPLICATION AFFIRMATION

I hereby swear or affirm under the penalties of perjury that the statements made in this application are true, complete and correct.

Signature of applicant

Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing

Agency or the Indiana Real Estate Appraiser Licensure and Certification Board, any files, documents, records or other information pertaining to the

undersigned requested by the Agency, or the Commission, or any of its authorized representatives in connection with processing my application for

licensure.

I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to

such inspection or furnishing of any such information.

I further authorize the Professional Licensing Agency and the Indiana Real Estate Appraiser Licensure and Certification Board to disclose to the aforementioned

persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby

specifically release the Agency and Commission from any and all liability in connection with such disclosures.

A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to the same.

Signature of applicant

Date signed (month, day, year)

NOTARY CERTIFICATE

STATE OF ________________________________________________

SS:

COUNTY OF ________________________________________________

I, _______________________________________________, being duly sworn on oath, say that I am the above-named applicant, that I have personally

prepared the foregoing application, and that the same is true to the best of my knowledge and belief.