Application For Provisional Status Form - State Board Of Assessors Page 5
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___________________________________
____________________________________
Employer
Employer
___________________________________
____________________________________
County Located In
County Located In
___________________________________
____________________________________
Address
Address
___________________________________
____________________________________
___________________________________
____________________________________
City, State, Zip
City, State, Zip
Outside Activities
Please check the appropriate item(s).
At least one item must be
checked. If during the period from July 1, 2003 to June
30, 2004, you performed any of these outside activities, you must inform us. If you performed Fee Appraiser and/or Real
Estate Sales activities, you
MUST
list
ALL
the jurisdictions where these activities were performed. Notice: Your employer
will be notified of these activities.
Property Management __ Property Tax Representative __
Fee Appraiser ___ Real Estate Sales __
Property Tax Consultant__ Insurance Sales __
_________________________________________
_________________________________________
_________________________________________
I do not perform any of these outside activities ___
_________________________________________
_________________________________________
I certify that the above information is true and correct to the best of my knowledge.
_________________________________________
_________________________
Signature of Applicant
Date
Have you enclosed?
• $65.00 Application Fee made payable to the Minnesota State Board of Assessors
• $35.00 Form Report Grading Fee
• Copies of course completion certificates.
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
Revised: July, 2004
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