Application For Provisional Status Form - State Board Of Assessors
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9MINNESOTA
STATE BOARD OF ASSESSORS
APPLICATION FOR PROVISIONAL STATUS
IMPORTANT: Print or Type ABOVE the Line.
PERSONAL DATA: Collection of data relating to gender, date of birth and residency is required
by MN Statute 214.07 (i)
_____________________
___________________ ___ _____ - ____ -_________
Last Name
First Name
MI
Social Security Number
_____________________________ _______________________ ____ _______
Home Address (Street and Number)
City
State Zip code
________________________________
(___) _____________
County of Residence
Home Phone Number
(Area Code and Number)
Date of Birth (M/D/Y):____________ Gender (Circle): Male Female
Have you ever been convicted of a felony? (Circle): Yes
No
Appraiser License Number (if applicable):_________________
ASSESSMENT COURSES
Name of Course
Sponsored by
Dates Attended
(1) _________________________ _______________________ ______________
(2) _________________________ _______________________ ______________
(3) _________________________ _______________________ ______________
I certify that the above information is true and correct to the best of my knowledge.
___________________________________
___________________________
Signature of Applicant
Date
Have you enclosed?
Copies of course completion certificates. Photocopy of Appraisers License (if applicable).
Return with this application form to:
Minnesota State Board of Assessors
Mail Station 3340
St. Paul, MN 55146-3340
Phone: (651) 556-6086
Fax: (651) 556-3128
Applications are acted upon at the next scheduled Board meeting following receipt of the application. There is no fee for
provisional status applications.
Revised: January 2004
47
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