Form Il 505-0338 - Real Estate Pre-License Education Instructor Application - 2011 Page 2
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3REAL ESTATE PRE-LICENSE EDUCATION INSTRUCTOR APPLICATION
ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
512
Division of Professional Regulation/Real Estate Professions Section
320 West Washington Street
Springfield, IL 62786
217/785-9300
Important Notice: Completion of this form is necessary to accomplish the requirements outlined in the Illinois Real Estate Act of 2000 {225 ILCS 454}.
Disclosure of this information is REQUIRED. Failure to comply may result in this form not being processed. This form has been approved by the Agency Forms
Coordinator.
1. Name:
Last,
First
Middle
2. Date of Birth
3. Social Security
_ _ /
_ _ / _ _
_ _ _ - _ _ - _ _ _ _
Month Date Year
4. Address: (Include Street, City, State and Zip Code)
5. Work Telephone No. (Include
area code)
Email Address:
( _ _ _ ) _ _ _ - _ _ _ _
6. Name and Address of School: (If known)
7. School Telephone No.
(Include area code)
( _ _ _ ) _ _ _ - _ _ _ _
8. List specific Pre-License courses you plan to teach.
9. School License Number
510 -
10. I certify that I have completed an IDFPR approved 12 hour pre-license instructor training program*
[ ] Yes
*Successful completion of the 12 hour instructor training program is a requirement for licensure.
Please see this web page for a list of schools approved for the Pre-License Instructor Training Program:
11. Personal History Information
[ ]
YES
[ ]
NO
Are you more than 30 days in arrears on any court ordered Child
Support Payments?
[ ]
YES
[ ]
NO
Have you ever been convicted of a crime which you have not previously
reported in writing to this office?
[ ]
YES
[ ]
NO
Have you had any professional license or permit in this or any other
jurisdiction disciplined and not previously reported the action in writing
to this office?
[ ]
YES
[ ] NO
Are you in arrears on any state taxes due to the Illinois Department of
Revenue?
[ ]
YES
[ ] NO
Are you in arrears on any Student loan acquired through the Illinois
Student Assistance Commission?
IL 505-0338 (Rev 5/11)
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